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Contract 47293
GITysEcwETARN Lfral{,3 CONTRACT P10. STATE OF TEXAS COUNTY OF TARRANT This contract ("Contract") is made and entered into by and between the City of Fort Worth (hereafter "City") and Tarrant County Samartian House, Inc. (hereafter "Agency"), a Texas non- profit corporation. City and Agency may be referred to individually as a "Party" and jointly as "the Parties". The Parties state as follows: WHEREAS, City receives grant monies from the United States Department of Housing and Urban Development through the Housing Opportunities for Persons with AIDS Program ("HOPWA") Program, Program No. TX-H-15-F002, Catalog of Federal Domestic Assistance No. 14.241; WHEREAS, the HOPWA program is intended to address the needs of eligible persons associated with the challenge of living with HIV/AIDS and their families; WHEREAS, Agency submitted a proposal to use HOPWA funds for an eligible program under the HOPWA Regulations whereby Agency will provide services to low and moderate income City citizens; WHEREAS, City citizens, the Community Development Council, and the City Council have determined that HOPWA programs are needed by the City's citizens; NOW, THEREFORE, the Parties understand and agree as follows: 1. INCORPORATION OF RECITALS City and Agency hereby agree that the recitals set forth above are true and correct and form the basis upon which the Parties have entered into this Contract. 2. DEFINITIONS In addition to terms defined in the body of this Contract, the terms set forth below shall have the definitions ascribed to there as follows: Area Median Income or AMI means the median family income for the Fort Worth -Arlington metropolitan statistical area as established annually by HUD. The 2015 income limits are attached hereto as EXHIBIT "A-1" — 2015 HUD Income Limits. Business Diversity Enterprise Ordinance or BDE means the City's Business Diver Ordinance, Ordinance No. 20020-12-2011. Complete Documentation means the following documentation as applicable: HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. OFFOCIAL, RECORD 1TV SECRETARY V'i", WORTh, TX /43"et /it% RECEIVED `v) DE -1 2015 Oil Page g Rev.g10.02.2Q 15 FORT V OR.TH °�, II'11 SECRETARY • Attachments I, II, and III, with supporting documentation including: o Proof of expense: copies of timesheets, invoices, leases, service contracts or other documentation showing that payment is due by Agency. o Proof of payment cancelled checks, bank statements, or wire transfers necessary to demonstrate that amounts due by Agency were actually paid by Agency. o Proof of client eligibility Source Documentation sufficient to show that clients participating in the Program are HOPWA Eligible Clients as described in Section 6. • Complete Documentation shall meet the standards described in the attached EXHIBIT "F"- Standards for Complete Documentation. • Any other document or record reasonably necessary to verify costs spent and client eligibility for the Program. DBE means disadvantaged business enterprise in accordance with 49 CFR Part 26. Director means the Director of the City's Neighborhood Services Department Effective Date means October 1, 2015. HOPWA means Housing Opportunities for Persons with AIDS HOPWA Eligible Client means a client whose annual income adjusted for family size does not exceed 80% of AMI using the most current HUD Income Guidelines and Technical Guidance for Determining Income and Allowances verified by either Source Documentation or the foul' in in EXHIBIT "E" - Form of Income Self -Certification The client must also have a documented diagnosis of HIV/AIDS. HOPWA Funds means the HOPWA grant funds supplied by City to Agency under the terms of this Contract. HOPWA Regulations means regulations found at 24 CFR Part 574 et seq. HUD means the United States Department of Housing and Urban Development. IDIS means Integrated Disbursement Information System, HUD's project tracking system Neighborhood Services Department means the City's Neighborhood Services Department. OMB means the Office of Management and Budget. Program means the services described in EXHIBIT "A" - Program Summary. Reimbursement Request means all reports and other documentation described in Section 9. HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 2 Rev. 10 02 2015 Source Documentation means documentation of full household income of any type described under the definition of annual income in 24 CFR Part 5.609, including but not limited to copies of paychecks, Social Security and disability verification letters, interest or rental income statements, retirement income statements, child support and alimony verification, unemployment benefit letters, and the like. Unduplicated Clients means a count of HOPWA Eligible Clients served at least once in the Contract Term. HOPWA Eligible Clients served more than once in the Contract Term will only be counted the first time they are served when determining the total count of Unduplicated Clients 3. TERM. The term of this Contract begins on October 1, 2015 and terminates on September 30, 2016 unless earlier terminated as provided in this Contract. 4. DUTIES AND RESPONSIBILITIES OF CITY. 4.1 Provide HOPWA Funds. City shall provide up to $420,063.00 of HOPWA Funds under the terms and conditions of this Contract. 4.2 Monitor City will monitor the activities and perfouinance of Agency and any of its contractors, subcontractors or vendors as necessary, but no less than annually. Monitoring by City will include determining whether Agency is meeting the requirements of the HOPWA Regulations during the term of this Contract. 5. DUTIES AND RESPONSIBILITIES OF AGENCY. 5.1 Required Services. Agency shall perfoini the services described in EXHIBIT "A" — Program Summary in accordance with the terms and conditions of this Contract. 5.2 Use of HOPWA Funds. 5.2.1. Compliance with HOPWA Regulations and Contract. Agency shall be reimbursed for eligible Program costs with HOPWA Funds only if City determines in its sole discretion that: 5.2.1.1 Costs are eligible expenditures in accordance with HOPWA Regulations. 5.2.1.2 Costs are in compliance with this Contract and are reasonable and consistent with industry norms. 5.2.1.3 Complete Documentation, as applicable, is submitted to City by Agency. 5.2.2 Budget 5.2.2.1 The HOPWA Funds will be paid on a reimbursement basis in accordance with EXHIBIT "B" - Budget. HOPWA PSA CONTRACT 2015-2016 Page 3 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 5.2.2.2 During the term of this Contract, Agency may submit written requests to increase or decrease line -item amounts in the Budget, including an explanation of why such increases or decreases are necessary. All such requests must be approved by the Director in writing, with such approval being in the Director's sole discretion. If Directoi approves the Agency's proposed Budget amendment (as approved, the `Amended Budget"), then the Amended Budget will take effect on the first day of the month following the month in which it was approved by Director, unless otherwise specified in the amendment All requests foi Budget amendments must be submitted by June 1, 2016. 5.2.3 Change in Program Budget. 5.2.3.1 Agency will notify City promptly of any additional funds it receives for operation of the Program, and City reserves the light to amend this Contract in such instances to ensure compliance with HUD regulations governing cost allocation 5.2.3.2 Agency agrees to utilize the HOPWA Funds to supplement rather than supplant funds otherwise available for the Program. 5.2.4 Payment of HOPWA Funds to Agency. HOPWA Funds will be disbursed to Agency upon City's approval of Reimbursement Requests including submission of Complete Documentation to City in compliance with Section 9. If Agency expends all funds budgeted for the Program prior to September 30, 2016, City may hold back a small amount of the HOPWA Funds until the end of the term. During this interim period, Agency must continue to submit Reimbursement Requests with an invoiced amount of $0. It is expressly agreed by the Parties that any HOPWA Funds not spent or not approved for reimbursement to Agency shall remain with City. 5.3 Program Performance Milestones. 5.3.1 Agency represents that the Program will achieve the following accordance with EXHIBIT "A" — Program Summary and the table below: Month 3 6 8 12 Expenditures 25% 50% 75% 100% Unduplicated Clients as specified in EXHIBIT "A" — Program Summary 25% 50% 75% 100% milestones in 5.3.2 Failure of Agency to meet these milestones or a material deviation from them as outlined in this Section 5.3 is a breach of this Contract. For the purpose of this Section, "material HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 4 Rev. 10 02 2015 deviation" shall mean more than 10% lower than the specified goal In the event of such breach, City reserves the right in its sole option to delay or withhold payment of Reimbursement Requests, to lower Agency's allocation of HOPWA Funds, or to terminate this Contract. 5.3.3 Failure to meet at least 80% of its performance milestones or serve 128 Unduplicated Clients will automatically disqualify Agency for consideration under the City's Request for Proposals for the 2016-2017 Program Year for federal grant funds. 5.3.4 Amendments to performance milestones must be approved by the Director in writing, with such approval being in the Director's sole discretion If Director approves the Agency's proposed amended performance milestones (as approved, the ` Amended Performance Milestones"), then the Amended Performance Milestones will take effect on the first day of the month following the month in which it was approved by Director unless otherwise specified in the amendment All requests for amendments to performance milestones must be submitted by June 1, 2016. Notwithstanding the above, any amendments to this Contract shall not reduce the number of Unduplicated Clients stated in Section 5.3.3 and in EXHIBIT "A" - Program Summary. 5.4 Identifv Program Expenses Paid with HOPWA Funds. Agency will keep accounts and records in such a manner that City may readily identify and account for Program expenses reimbursed with HOPWA Funds. These records shall be made available to City for audit purposes and shall be retained as required hereunder. 5.5 Program Subcontracts. Agency shall not enter into a subcontract with another agency, contractor, or vendor to provide a service to clients for any part of the Program that will be paid with HOPWA Funds without City's written consent 6. CLIENT ELIGIBILITY VERIFICATION. 6.1 Client Eligibility Agency will document the eligibility of all prospective clients Agency may redact the client's personal information and substitute a client number. Agency will document client eligibility as follows: 6.1.1 Income. Agency must verify all new clients' income eligibility with either Source Documentation or the form attached as EXHIBIT "E" - Form of Income Self Certification Agency must use the annual income definition used by 24 CFR Part 5.609 to establish client income eligibility and must use the most current HUD Income Guidelines 6.1.2 Diagnosis. Agency must submit a signed, dated statement that the client's file contains documentation of the client's diagnosis of HIV/AIDS The HIV/AIDS diagnosis must be made by a licensed health care provider; a client s self -certification of diagnosis is not sufficient Agency should not submit the actual diagnosis to City. HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 5 Rev. 10.02.2015 6.1.3 Emergency Need. For clients receiving short term rental, mortgage or utility assistance, Agency must also verify and document that the client has an emergency need, such as sudden loss of income, eviction, utility shutoff, or extraordinary and unexpected healthcare costs. Agency must submit its policy regarding documenting emergency need to City by October 1, 2015. 6.2 Submission of Comnlete Documentation. Agency must submit copies of documentation of client eligibility described in Section 6.1 with Attachment III in each month's Reimbursement Request for all Unduplicated Clients 6.3 Maintain Documentation. Agency must maintain copies of all documentation required by this Section 6 for 5 years following the expiration of the Contract term. This Section shall survive the earlier terminations or expirations of this Contract. 7. ADDITIONAL HOPWA REOUIREMENTS. Agency agrees to comply with all requirements of the HOPWA Program as stated in the HOPWA Regulations, including but not limited to the following* 7.1 Environmental Review. HOPWA Funds will not be paid, and costs cannot be incurred until City has conducted an environmental review and completed an Environmental Review Record as required by 24 CFR Part 58. The environmental review may result in a decision to proceed with, modify, or cancel the funding for the Program. Further, Agency will not undertake or commit any funds to physical or choice limiting actions as described in any applicable federal regulations. Any violation of this provision will (i) cause this Contract to teimrnate immediately; and (ii) require Agency to repay City the HOPWA Funds it has already received and forfeit any future payments of HOPWA Funds. 7.2 Contract Not Constituting Commitment of Funds. Notwithstanding any provision of this Contract, the Parties agree and acknowledge that this Contract does not constitute a commitment of funds, and that such commitment of funds or approval may occur only upon (i) satisfactory completion of environmental review and receipt by City of an authorization to use grant funds from HUD under 24 CFR Part 58, (ii) approval of City's 2015-2016 Action Plan, and (iii) receipt by City of grant agreement from HUD. 7.3 Monitoring. 7.3.1 Agency understands and agrees that it will be subject to monitoring by City for compliance with terms and provisions of this Contract and the HOPWA Regulations for the term of this Contract. Agency is subject to such monitoring during the term of this Contract and for 5 years after the Contract teruu ends Agency will provide reports and access to Program files as requested by City during this 5 year period. For purposes of this Contract, this 5 year period for monitoring is deemed to begin on October 1 2016 and end on September 30, 2021 regardless of whether or not this Contract is earlier terminated. HOPWA PSA CONTRACT 2015-2016 TalTant County Samat itan House, Inc. Page 6 Rev. 10 02 2015 7.3.2 Representatives of City, HUD, HUD Office of Inspector General, and the United States Comptroller General shall have access during regular business hours, upon 48 hours prior notice, to Agency's offices and records pertaining to the use of the HOPWA Funds, and to Agency's officers, directors, agents, employees, contractors, subcontractors and vendors for the purpose of such monitoring. 7.3.3 In addition to other provisions of this Contract regarding frequency of monitoring, City reserves the right to perform desk reviews or on -site monitoring of Agency's compliance with the terms and conditions of this Contract. City shall provide Agency with a written report of the monitor's findings after each monitoring visit. If the monitoring report notes deficiencies in Agency's performance, the report shall include requirements for the timely correction of said deficiencies by Agency. Failure by Agency to take the action specified in the monitoring report may be cause for suspension or termination of this Contract as provided herein. 7.3.4 Subsections 7.3.1 through 7.3.3 shall be applicable for the Contract tents and for 5 years thereafter and shall survive the earlier termination or expiration of this Contract. 7.3.5 Agency shall provide City annually the results of any state or federal monitoring. Such results shall be submitted within 60 days of receipt of such state or federal monitoring report, or with the January Reimbursement Request, whichever is earlier 7.4 Atencv Procurement Standards. Agency shall comply with all applicable federal, state and local laws, regulations, and ordinances for making procurements under this Contract. In addition to the conflict of interest provision in Section 14.13.3 Agency shall establish written procurement procedures to ensure that materials and services are obtained in a cost effective manner and that provides for full and open competition When procuring materials and services for this Contract, Agency shall comply at a minimum with the procurement standards in 2 CFR Part 200.317 through 2 CFR Part 200.326. 7.4.1 Contracts in excess of $10,000.00 made by Agency using CDBG Funds must address termination for cause and convenience including the manner by which such termination shall be effected and the basis for settlement of the terminated contract, if any, as required by Appendix II (B), 2 CFR Part 200. 7.4.2 Agency shall not make any contract with parties listed on the governmentwide System for Award Management, www.sam gov ("SAM"). Agency must confinn by search of SAM that all contractors paid with CDBG Funds are not listed by SAM as being debarred, both prior to hiring and prior to submitting a Reimbursement Request which includes invoices from any such contractor. Failure to submit such proofs of search shall be an event of default. 7.5 Cost Principles/Cost Reasonableness. Agency shall administer its use of HOPWA Funds in compliance with 2 CFR Part 200, as applicable. The eligibility of costs incurred for performance rendered shall be determined in accordance 2 CFR Part 200.400 through 2 CFR Part 200.475. HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 7 Rev. 10.02.2015 7.6 AccountinE Standards. Agency agrees to comply with 2 CFR Part 200, as applicable. Agency also agrees to adhere to the accounting principles and procedures required therein, utilize adequate internal controls, and maintain necessary supporting and back-up documentation for all costs incurred in accordance with 2 CFR Part 200.302 and Part 200.303. 7.7 Uniform Administrative Requirements, Cost Principles, and Audit Requirements. Agency will comply with the Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards in 2 CFR Part 200, as applicable, or any reasonably equivalent procedures and requirements that City may require. 7.8 Terms Applicable to Contractors, Subcontractors and Vendors. Agency understands and agrees that all terms of this Contract, whether regulatory or otherwise, shall apply to any and all contractors, subcontractors and vendors of Agency which are in any way paid with HOPWA Funds or who perform any work in connection with the Program. Agency shall cause all applicable provisions of this Contract to be included in and made a part of any contract or subcontract executed in the performance of its obligations hereunder including its obligations regarding the HOPWA Regulations Agency shall monitor the services and work performed by its contractors, subcontractors and vendors on a regular basis for compliance with the HOPWA Regulations and Contract provisions. Agency must cure all violations of the HOPWA Regulations committed by its contractors, subcontractors or vendors. City maintains the right to insist on Agency's full compliance with the terms of this Contract and the HOPWA Regulations and Agency is responsible for such compliance regardless of whether actions taken to fulfill the requirements of this Contract are taken by Agency or by Agency's contractors, subcontractors or vendors. Agency acknowledges that the provisions of this Section shall survive the earlier termination or expiration of this Contract and shall be applicable for 5 years after the Contract Term ends 7.9 Copvriuht and Patent RiEhts No reports, maps, or other documents produced in whole or in part under this Contract shall be the subject of an application for copyright by or on behalf of Agency. HUD and City shall possess all rights to invention or discovery, as well as rights in data, which may arise as a result of Agency's performance under this Contract. 7.10 Conflict of Interest Disclosure. In accordance with the requirements of Section 14.13.2 1 and 14.13.4, Agency shall establish conflict of interest policies for federal awards Agency shall disclose to City in writing any potential conflict of interest. 7.11 Compliance with FFATA and Whistleblower Protections. Agency shall comply with the requirements of 2 CFR 300(b), including provisions of the Federal Funding Accountability and Transparency Act ("FFATA ') governing requirements on executive compensation and provisions governing whistleblower protections contained in 10 U.S.C. 2409, 41 U.S.C. 4712, 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310. HOPWA PSA CONTRACT 2015-2016 Page 8 Tarrant County Samaritan House, Inc Rev. 10 02 2015 7.11.1 Agency shall provide City with its DUNS number. 7.12 Internal Controls. In compliance with the requirements of 2 CFR Part 200.303, Agency shall• 7.12.1 Establish and maintain effective internal control over the HOPWA Funds that provides reasonable assurance that Agency is managing the HOPWA Funds in compliance with federal statutes, regulations, and the terms and conditions of this Contract. These internal controls shall be in compliance with guidance in "Standards for Internal Control in the Federal Government" issued by the Comptroller General of the United States or the "Internal Control Integrated Framework" issued by the Committee of Sponsoring Organizations of the Treadway Commission ("COSO"); 7.12.2 Comply with federal statutes, regulations, and the terms and conditions of this Contract; 7.12.3 Evaluate and monitor Agency's compliance with statutes, regulations and the terms and conditions of this Contact; 7.12.4 Take prompt action when instances of noncompliance are identified including noncompliance identified in audit findings; and 7.12.5 Take reasonable measures to safeguard protected personally identifiable information and other information that HUD or City designates as sensitive or Agency considers sensitive consistent with applicable federal, state, local and tribal laws regarding privacy and obligations of confidentiality 7.13 Required Certification of Completion of Training. At least 1 Agency employee must complete the HUD required "Getting to Work Training Curriculum" by April 15, 2016 and submit the required certifications to City with the April 2016 Reimbursement Request as more particularly described on EXHIBIT "A-2" - Requirements for Completion of ` Getting to Work Training Curriculum". 8. RECORD KEEPING; REPORTING AND DOCUMENTATION REQUIREMENTS; AUDIT. 8.1 Record Keeping. Agency shall maintain a record -keeping system as part of its performance of this Contract and shall promptly provide City with copies of any document City deems necessary for the effective fulfillment of City's monitoring and evaluation responsibilities. Specifically, Agency will keep or cause to be kept an accurate record of all actions taken and all funds spent, with supporting and back-up documentation. Agency will maintain all records and documentation related to this Contract for 5 years after the Contact term ends If any claim, litigation, or audit is initiated before the expiration of the 5 year period, the relevant records and documentation must be retained until all such claims, litigation or audits have been resolved. For purposes of this Contract, this 5 year period for record retention is deemed to begin on October 1, 2016 and end on September 30, 2021 regardless of whether or not this Contract is earlier terminated. HOPWA PSA CONTRACT 2015-2016 Page 9 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 8.2 Access to Records. Representatives of City, HUD and any duly authorized officials of the federal government will have full access to, and the right to examine, audit, copy, excerpt and/or transcribe any of Agency's records pertaining to all matters covered by this Contract for 5 years after the Contract term ends Such access shall be during regular business hours and upon at least 48 hours prior notice. For purposes of this Contract, this 5 year period for access to records is deemed to begin on October 1, 2016 and end on September 30, 2021 regardless of whether or not this Contract is earlier terminated. 8.3 Reports. Agency will submit to City all reports and documentation described in this Contract in such foam as City may prescribe. Agency may also be required to submit a final performance and/or final financial report if required by City at the termination of this Contract in such form and within such times as City may prescribe. Failure to submit to City any report or documentation described in this Contract shall be an event of default of this Contract and City may exercise all of its remedies for default under this Contract. 8.3.1 Additional Information. Agency shall provide City with additional information as may be required by state or federal agencies to substantiate Program activities and/or expenditure eligibility. 8.4 Chancre in Reporting Requirements and Forms City retains the right to change reporting requirements and fonns at its discretion. City will notify Agency in writing at least 15 days prior to the effective date of such change, and the Parties shall execute an amendment to the Contract reflecting such change if necessary. 8.5 Audit 8.5.1 Entities that Expend $750,000 or more in Federal Funds Per Year All non-federal entities that expend $750,000 or more in federal funds within 1 year, regardless of the source of the federal award, must submit to City an annual audit prepared in accordance with specific reference to 2 CFR Part 200.501 through Part 200.521. The audit shall cover the Agency s fiscal years during which this Contract is in force. The audit must be prepared by an independent certified pubhc accountant, be completed within 6 months following the end of the period being audited and be submitted to City within 30 days of its completion Agency's audit certification is attached hereto as EXHIBIT "C" - "Audit Certification Form" and "Audit Requirements". The Audit Certification Form must be submitted to City prior to or with the first Reimbursement Request. Entities that expend less than $750,000 a year in federal funds are exempt from federal audit requirements for that year, but records must be available for review or audit by appropriate officials of the federal agency, City, and General Accounting Office. 8.5.2 City Reserves the Riaht to Audit. City reserves the right to perform an audit of Agency's Program operations and finances at any time during the term of this Contract and for 5 years after the Contract Term ends if City determines that such audit is necessary for City's compliance with the HOPWA Regulations or HOPWA PSA CONTRACT 2015-2016 Page 10 Tarrant County Samaritan House, Inc. Rev. 10 02 2015 other City policies. Agency agrees to allow access to all pertinent materials as described herein for such audit. For purposes of this Contract, this 5 year period for City audit is deemed to begin on October 1, 2016 and end on September 30, 2021 regardless of whether or not this Contract is earlier terminated. If such audit reveals a questioned practice or expenditure, such questions must be resolved within 15 business days after notice to Agency of such questioned practice or expenditure. If questions are not resolved within this period, City reserves the right to withhold further funding under this Contract and/or any other contracts with Agency. IF AS A RESULT OF ANY AUDIT IT IS DETERMINED THAT AGENCY HAS FALSIFIED ANY DOCUMENTATION OR MISUSED, MISAPPLIED OR MISAPPROPRIATED HOPWA FUNDS OR SPENT HOPWA FUNDS ON ANY INELIGIBLE ACTIVITIES, AGENCY AGREES TO REIMBURSE CITY THE AMOUNT OF SUCH MONIES PLUS THE AMOUNT OF ANY SANCTIONS, PENALTY OR OTHER CHARGE LEVIED AGAINST CITY BY HUD BECAUSE OF SUCH ACTIONS. 9. REIMBURSEMENT REOUIREMENTS 9.1 Deadline for Submitting Reimbursement Requests. 9.1.1 Reimbursement Requests shall be submitted monthly to the City and must be received by the City on or before the 15th day of the month following the month expenses were paid by Agency. For example, the Reimbursement Request for June expenses must be received by July 15 In the event the 15th falls on a weekend or City holiday, Reimbursement Requests shall be due the next day that the City is open for business. Failure to submit a Reimbursement Request in a timely fashion will result in City taking the actions outlined in Section 101. NOTWITHSTANDING ANYTHING ABOVE, THE REIMBURSEMENT REQUEST FOR EXPENSES INCURRED FOR SEPTEMBER 2016 MUST BE RECEIVED BY OCTOBER 1, 2016. FAILURE TO SUBMIT A FINAL REIMBURSEMENT REQUEST WITH COMPLETE DOCUMENTATION BY OCTOBER 15, 2016 WILL RESULT IN FORFEITURE OF PAYMENT OF THE SEPTEMBER REIMBURSEMENT REQUEST. 9.1.2 City will notify Agency by e-mail within 20 calendar days if a Reimbursement Request is lacking Complete Documentation or corrections are needed. Agency will have 10 business days from the date of the e-mail notice to submit any requested information or missing documentation. Agency will be penalized in the Request for Proposal for the 2016-2017 Program Year for any notifications received under this Section If Agency fails to submit all the required information or missing documentation within 30 calendar days from the first e-mail, Agency shall forfeit any payments otherwise due that month and failure to submit any requested information will be considered an event of default as outlined in Section 10.1.2. 9.2 Submission of Reimbursement Requests. Agency shall provide City with Complete Documentation and the following reports as shown in EXHIBIT "D" - Reimbursement Forms with each Reimbursement Request: 9.2.1 Attachment I - Invoice This report shall contain the amount requested for reimbursement each month, the cumulative reimbursement requested to date (inclusive of that month's request), and must be HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 11 Rev. 10 02 2015 signed by an authorized signatory of Agency By signing Attachment I, Agency is certifying that the costs are valid, eligible, consistent with the terms and conditions of this Contract, and the data contained in the report is true and correct. This report must be submitted even if Agency is requesting $0 for a particular month. 9.2.1.1 Agency must submit a separate invoice for each activity type, i.e. Administration, Facility Based Operating Costs, Supportive Services, Short-term Rent, Mortgage and Utility Assistance (`STRMU"), and Tenant Based Rental Assistance ("TBRA"). 9.2.2 Attachment II - Expenditure Worksheet This report shall itemize each expense requested for reimbursement by Agency and shall include the Account corresponding the expense to a Budget line item. In order for this report to be complete the following must be submitted: 9.2.2.1 For payroll expenses, timesheets signed by employees and approved by supervisor for all payroll expenses listed. Timesheets must distinguish between HOPWA-funded time and non-HOPWA funded time and reflect actual time spent on HOPWA-funded activities. Agency may not submit payroll expenses dated 60 calendar days prior to the date of the Reimbursement Request. 9.2.2.2 For non -payroll expenses, invoices for each expense listed with an explanation as to how the invoiced expense pertains to the Program. Agency may not submit invoices dated 60 calendar days prior to the date of the Reimbursement Request. 9.2.2.3 Proof that each expense was paid by Agency, which proof can be satisfied by canceled checks, wire transfer documentation, paid receipts or other appropriate banking documentation. 9.2.3 Attachment III - Client Data Report. This report shall list each Unduplicated Client served during the month along with his or her demographic information. The Client Data Report must maintain a list of all clients served during the Contract teuu In order foi this report to be complete, the following must be submitted: 9.2.3.1 Documentation of income verification for each Unduplicated Client the first time the client is served by the Program, which will either be the completed faun of EXHIBIT `E"- Form of Income Self Certification or Source Documentation 9.2.4 Overview Report. Agency shall submit the Overview Report, attached hereto as EXHIBIT "H" - Overview Report, quarterly with the January, April, July and October Reimbursement Requests. A paper copy must be submitted with the Reimbursement Request, and an electronic copy must also be emailed to psa(a�fortworthtexas.gov. HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 12 Rev. 10.02.2015 9.2.5 Delivery of Reimbursement Request Reimbursement Requests can be mailed or delivered in person to Neighborhood Services Department, 908 Monroe Street, Fort Worth, Texas 76102. In addition, Agencies can submit Reimbursement Requests via email to nsa(a,fortworthtexas.gov, but Agency must submit a signed original of Attachment I by the deadline in Section 9 1 1 9.3 Withholding Payment. CITY SHALL HAVE NO OBLIGATION TO PAY ANY REIMBURSEMENT REQUEST THAT IS NOT RECEIVED BY THE DUE DATE. Failure to timely submit Reimbursement Requests and Complete Documentation along with any required reports shall be an event of default. 10. DEFAULT AND TERMINATION. 10.1 Failure to Submit Reimbursement Request or Required Documentation. 10.1.1 If Agency fails to submit a Reimbursement Request in accordance with Section 9, Agency shall be in default of this Contract. City will notify Agency in writing of such default and the Agency will have 10 business days from the date of the written notice to submit such Reimbursement Request to cure the default If Agency fails to cure the default within such time, Agency shall forfeit any payments otherwise due that month 10.1.2 If Agency fails to submit requested infonnnation or missing documentation as set forth in Section 9.1.2, then Agency shall forfeit payment due that month and the failure to submit shall be considered an event of default that shall not be cured. 10.1.3 NOTWITHSTANDING THE PROVISIONS OF SECTION 10.1.1 OR 10.1.2, IF AGENCY FAILS TO SUBMIT THE REIMBURSEMENT REQUEST DUE OCTOBER 1, 2016, OR IF THE SUBMITTED REIMBURSEMENT REQUEST FOR OOCTOBER 1, 2016 IS LATE, INCOMPLETE OR OTHERWISE NOT IN COMPLIANCE WITH THIS CONTRACT OR THE HOPWA REGULATIONS AS DETERMINED BY CITY IN ITS SOLE DISCRETION, THERE WILL BE NO CURE PERIOD AND ANY REIMBURSEMENT WILL BE FORFEITED. 10.1.4 In the event of (i) an uncured default under Section 10.1.1 or an event of default under 10.1.2 (ii) or more than 2 instances of default, cured or uncured, under these Sections, City reserves the right at its sole option to terminate this Contract effective immediately upon written notice of such intent with no penalty or liability to City. 10 1.5 Notwithstanding anything to the contrary herein, City will not be i equired to pay any HOPWA Funds to Agency during the period that any Reimbursement Request, report or documentation is past due or is not in compliance with this Contract or the HOPWA Regulations, or during any period during which Agency is in default of this Contract. HOPWA PSA CONTRACT 2015-2016 Page 13 Tarrant County Samaritan House, Inc Rev. 10 02 2015 10.1.6 In the event of teiruination under this Section 10.1, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have no further right to such funds. 10.2 Failure to Maintain Records or Submit Reports and Documentation. If Agency fails to maintain all records and documentation as required in Section 8, or if the maintained or submitted report or documentation is not in compliance with this Contract or the HOPWA Regulations as deteunined by City in its sole discretion, City will notify Agency in writing and Agency will have 30 calendar days from the date of the written request to obtain or recreate the missing records and documentation or submit or resubmit any such report or documentation to City. If Agency fails to maintain the required reports or documentation, or fails to submit or resubmit any such report or documentation within such time, City shall have the right to terminate this Contract effective immediately upon written notice of such intent with no penalty or liability to City. 10.2.1 In the event of teunination under this Section 10.2, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have no further right to such funds, and any HOPWA Funds paid to Agency must be repaid to City within 30 days of teirnination If such HOPWA funds are not repaid to City within the 30 day period, City shall exercise all legal remedies available under this Contract. 10.3 In General. 10.3.1 Subject to Section 10.2, and unless specifically provided otherwise in this Contract, Agency shall be in default under this Contract if Agency breaches any term or condition of this Contract In the event that such a breach remains uncured after 30 calendar days following written notice by City (or such other notice period as may be specified herein) or, if Agency has diligently and continuously attempted to cure following receipt of such written notice but reasonably requires more than 30 calendar days to cure, as determined by both Parties mutually and in good faith, City shall have the right to elect in City's sole discretion to (i) extend Agency's time to cure, (ii) terminate this Contract effective immediately upon written notice of such intent to Agency, or (iii) pursue any other legal remedies available to City under this Contract. 10.3.2 City's remedies may include: 10.3.2.1 Direct Agency to prepare and follow a schedule of actions for carrying out the affected activities, consisting of schedules, timetables and milestones necessary to implement the affected activities. 10.3.2.2 Direct Agency to establish and follow a management plan that assigns responsibilities for carrying out the remedial activities. 10.3.2.3 Reprogram HOPWA Funds that have not yet been expended from affected activities to other eligible activities or withhold HOPWA Funds. HOPWA PSA CONTRACT 2015-2016 Page 14 Tarrant County Samaritan House, Inc Rev. 10.02.2015 10.3.2.4 Any other appropriate action including but not limited to any remedial action legally available such as declaratory judgment, specific perfoiniance, damages, temporary or permanent injunctions, termination of this Contract or any other contacts with Agency, and any other available remedies. 10.3 3 In the event of termination under this Section 10.3, all IIOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately forfeited and Agency shall have no further right to such funds, and any HOPWA Funds already paid to Agency must be repaid to City within 30 days of the teiniination Failure to repay such HOPWA Funds within the 30 day period will result in City exercising all legal remedies available under this Contract. 10.4 No Funds Disbursed while in Breach. Agency understands and agrees that no HOPWA Funds will be paid to Agency until all defaults are cured to City's satisfaction 10.5 No Comnensation After Date of Termination. Agency shall not receive any compensation for work undertaken after the date of the termination 10.6 Rights of City Not Affected. Termination shall not affect or tettninate any of the existing rights of City against Agency, or which may thereafter accrue because of Agency's default and this provision shall be in addition to any and all other rights and remedies available to City under the law. Such termination does not terminate any provisions of this Contract that have been expressly noted as surviving the terns or termination of the Contract. No delay or omission by City in exercising any right or remedy available to it under this Contract shall impair any such right or remedy or constitute a waiver or acquiescence in any Agency default. 10.7 Waiver of Breach Not Waiver of Subsequent Breach The waiver of a default or breach of any term, covenant, or condition of this Contract shall not operate as a waiver of any subsequent default or breach of the same or any other term, covenant or condition hereof. 10.8 Civil, Criminal and Administrative Penalties Failure to perform all the Contract terms may result in civil, criminal or administrative penalties, including, but not limited to those set out in this Contract. 10.9 Termination for Cause 10.9.1 City may terminate this Contract in the event of Agency's default, inability, or failure to perform subject to notice, grace and cure periods In the event City terminates this Contract for cause, all HOPWA Funds awarded but unpaid to Agency pursuant to this Contract shall be immediately rescinded and Agency shall have no further right to such funds and any HOPWA Funds already paid to Agency must be repaid to City within 30 days of termination. Failure to repay such HOPWA Funds within 30 days will result in City exercising all legal HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 15 Rev. 10 02 2015 remedies available to City under this Contract. AGENCY ACKNOWLEDGES AND AGREES THAT IF CITY TERMINATES THIS CONTRACT FOR CAUSE, AGENCY OR ANY AFFILIATES OF AGENCY SHALL NOT BE CONSIDERED FOR ANY OTHER CITY CONTRACT FOR HOPWA FUNDS FOR A MINIMUM OF 5 YEARS FROM THE DATE OF TERMINATION. 10.9.2 Agency may terminate this Contract if City does not provide the HOPWA Funds substantially in accordance with this Contract. 10.10 Termination for Convenience. In terminating in accordance with 2 CFR Part 200, Appendix II, this Contract may be terminated in whole or in part only as follows: 10.10.1 By City with the consent of Agency in which case the Parties shall agree upon the termination conditions, including the effective date and in the case of partial termination, the portion to be terminated; or 10.10.2 By Agency upon at least 30 days written notification to City, setting forth the reasons for such termination, the effective date, and in the case of partial termination, the portion to be terminated In the case of a partial termination, City may terminate the Contract in its entirety if City determines in its sole discretion that the remaining portion of the Contract to be performed or HOPWA Funds to be spent will not accomplish the purposes for which the Contract was made. 10.11 Dissolution of Agency Terminates Contract. This Contract shall terminate in the event Agency is dissolved or ceases to exist In the event of termination under this Section, all HOPWA Funds are subject to repayment and/or City may exercise all of its remedies under this Contract. 10.12 Reversion of Assets. In the event this Contract is terminated with or without cause, all assets acquired by Agency with the HOPWA Funds including cash, interest payments from loans or otherwise, all outstanding notes, mortgages or other security instruments any accounts receivable attributable to the use of the HOPWA Funds, and any real or personal property owned by Agency that was improved with the HOPWA Funds shall automatically transfer to City or to such assignee as City may designate. 11. REPAYMENT OF HOPWA FUNDS. All HOPWA Funds are subject to repayment in the event the Program does not meet the requirements of this Contract or in the HOPWA Regulations If Agency takes any action that results in the City being required to repay all or any portion of the HOPWA Funds to HUD, Agency agrees it will reimburse City for such repayment. If Agency takes any action that results in City receiving a finding from HUD about the Program, whether or not repayment of all or any portion of the HOPWA Funds is required of City, Agency agrees it will pay City 10% of the HOPWA Funds as liquidated damages. The Parties agree that City's damages in the event of either repayment to HUD being required or receiving a finding from HUD are HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc Page 16 Rev. 10 02 2015 uncertain and would be difficult to ascertain and may include an impact on City's HOPWA grant or other federal grant funds, in addition to the finding by HUD or a required repayment of funds to HUD by City. Therefoie, the Parties agree that payment under this Section of 10% of the HOPWA Funds by Agency to City is liquidated damages and not a penalty. 12. CHANGE IN NON-PROFIT STATUS. Agency must provide City with written notification of any changes to its non-profit status within 15 calendar days of being notified of the change If the non-profit status of Agency changes after the date of this Contract, City may but is not obligated to, teiniinate this Contract. City has 30 calendai days to make such deteiniination after receipt of written notice from Agency and failure to make such determination will constitute a waiver In the event of termination under this Section 12, all HOPWA Funds awarded but not yet paid to Agency pursuant to this Contract shall be immediately rescinded and Agency shall have no further right to such funds. Any HOPWA Funds already paid to Agency must be repaid to City within 30 calendar days of tenuination under this Section 13. SURVIVAL. Any provision of this Contract that pertains to auditing, monitoring, client income eligibility, record keeping and reports, City ordinances, or applicable HOPWA requirements, and any default and enforcement provisions necessary to enforce such provisions, shall survive the teiniination of this Contract for 5 years after the Contract tem' ends and shall be enforceable by City against Agency. For purposes of this Contract, this 5 year period for survival of certain Contract provisions is deemed to begin on October 1 2016 and end on September 30, 2021 regardless of whether or not this Contract is earlier terminated. 14. GENERAL PROVISIONS. 14.1 Aaencv an Independent Contractor. Agency shall operate hereunder as an independent contractor and not as an officer, agent, servant of employee of City. Agency shall have exclusive control of, and the exclusive right to control, the details of the work and services performed hereunder, and all persons performing same, and shall be solely responsible for the acts and omissions of its officers, members, agents, servants, employees, contractors, subcontractors, vendors, clients, licensees or invitees. 14.2 Doctrine of Respondeat Superior. The doctrine of respondeat superior shall not apply as between City and Agency, or its officers, members, agents servants, employees, contractors, subcontractors, vendors, clients, licensees or invitees, and nothing herein shall be construed as creating a partnership or joint enterprise between City and Agency City does not have the legal right to control the details of the tasks performed hereunder by Agency, its officers, members, agents, employees, contractors, subcontractors, vendors, clients, licensees or invitees. 14 3 Aaencv Property. City shall under no circumstances be responsible for any property belonging to Agency, or its officers, members, agents, employees, contractors, subcontractors, vendors, clients, licensees or HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 17 Rev. 10.02.2015 invitees that may be lost, stolen or destroyed or in any way damaged and AGENCY HEREBY INDEMNIFIES AND HOLDS HARMLESS CITY AND ITS OFFICERS, AGENTS, AND EMPLOYEES FROM ANY AND ALL CLAIMS OR SUITS PERTAINING TO OR CONNECTED WITH SUCH PROPERTY. 14.5 Religious Organization. No portion of the HOPWA Funds shall be used in support of any sectarian or religious activity In addition, there must be no religious or membership criteria for clients of a HOPWA- funded service. 14.6 Venue. Venue shall he in Tarrant County, Texas for any action whether real or asserted, at law or in equity, arising out of the execution, performance, attempted performance or non-performance of this Contract. 14.7 Governing Law. This Contract shall be governed by and construed in accordance with the laws of the State of Texas If any action, whether real or asserted, at law or in equity, arises out of the execution, performance or non-performance of this Contract of on the basis of any provision herein, for any issue not governed by federal law, the choice of law shall be the laws of the State of Texas. 14.8 Severability. The provisions of this Contract are severable, and if for any reason a clause, sentence, paragraph or other part of this Contract shall be determined to be invalid by a court or federal or state agency, board or commission having jurisdiction over the subject matter thereof, such invalidity shall not affect other provisions which can be given effect without the invalid provision. 14.9 Written Agreement Entire Contract. This written instrument and the Exhibits, Attachments, and Addendums attached hereto, which are incorporated by reference and made a part of this Contract for all purposes, constitute the entice agreement by the Parties concerning the work and services to be performed under this Contract. Any prior or contemporaneous oral or written agreement which purports to vary the teinis of this Contract shall be void. Any amendments to the terms of this Contract must be in writing and executed by the Parties. 14.10 Paragraph Headings for Reference Only, No Legal Significance; Number and Gender. The paragraph headings contained herein are for convenience in reference to this Contract and are not intended to define or to limit the scope of any provision of this Contract. When context requires, singular nouns and pronouns include the plural and the masculine gender shall be deemed to include the feminine or neuter and the neuter gender to include the masculine and feminine. The words "include ' and "including whenever used herein shall be deemed to be followed by the words "without limitation". 14.11 Compliance With All Applicable Laws and Regulations. Agency agrees to comply fully with all applicable laws and regulations that are currently in HOPWA PSA CONTRACT 2015-2016 Page 18 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 effect or that are hereafter amended during the performance of this Contract. Those laws include, but are not limited to: ➢ HOPWA Regulations found in 24 CFR Part 574 ➢ AIDS Housing Opportunity Act, as amended (42 USC 12901 et seq.) ➢ Title VI of the Civil Rights Act of 1964 (42 U.S.C. Sections 2000d et seq.) including provisions requiring recipients of federal assistance to ensure meaningful access by person of limited English proficiency ➢ The Fair Housing Act, Title VIII of the Civil Rights Act of 1968 (42 U.S.C. Sections 3601 et seq.) ➢ Executive Orders 11063, 11246 as amended by 11375 and 12086 and as supplemented by Department of Labor regulations 41 CFR Part 60 ➢ The Age Discrimination in Employment Act of 1967 ➢ The Age Discrimination Act of 1975 (42 U.S.C. Sections 6101 et seq.) ➢ The Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.0 Sections 4601 et seq. and 49 CFR Part 24) ("URA") ➢ Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. Sections 794 et seq.) and 24 CFR Part 8 where applicable ➢ National Environmental Policy Act of 1969, as amended, 42 U.S.C. Sections 4321 et seq. ("NEPA") and the related authorities listed in 24 CFR Part 58. ➢ The Clean Air Act, as amended, (42 U.S.C. Sections 1251 et seq.) and the Clean Water Act of 1977, as amended (33 U.S.C. Sections 1251 et seq.) and the related Executive Order 11738. In no event shall any amount of the assistance provided under this Contract be utilized with respect to a facility that has given rise to a conviction under the Clean Air Act or the Clean Water Act. ➢ Immigration Refoini and Control Act of 1986 (8 U.S.C. Sections 1101 et seq.) specifically including the provisions requiring employer verifications of legal status of its employees ➢ The Americans with Disabilities Act of 1990 (42 U.S.C. Sections 12101 et seq.), the Architectural Barriers Act of 1968 as amended (42 U.S.0 Sections 4151 et seq.) and the Uniform Federal Accessibility Standards, 24 CFR Part 40, Appendix A ➢ Regulations at 24 CFR Part 87 related to lobbying, including the requirement that certifications and disclosures be obtained from all covered persons ➢ Drug Free Workplace Act of 1988 (41 U.S.C. Sections 701 et seq.) and 24 CFR Part 23, Subpart F ➢ Executive Order 12549 and 24 CFR Part 5.105(c) pertaining to restrictions on participation by ineligible, debarred or suspended persons or entities ➢ Section 6002 of the Solid Waste Disposal Act, as amended by the Resource Conservation and Recovery Act ➢ Guidelines of the Environmental Protection Agency at 40 CFR Part 247 ➢ For contracts and subgrants for construction or repair, Copeland "Anti -Kickback" act (18 U.S.C. 874) as supplemented in 29 CFR Part 5 ➢ For construction contracts awarded by Agency in excess of $2,000, and in excess of $2,500 for other contracts which involve the employment of mechanics or laborers, Sections 103 and 107 of the Contract Work Hours and Safety Standards Act (40 U.S.C. 327A 300) as supplemented by 29 CFR Part 5 HOPWA PSA CONTRACT 2015-2016 Page 19 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 ➢ Lead -Based Paint Poisoning Prevention Act (42 U.S.C. 4801 et seq.), as amended by the Residential Lead -Based Paint Hazard Reduction Act of 1992 (42 U.S.C. 4851 et seq.) and implementing regulations at 24 CFR Part 35, subparts A, B, M, and R ➢ Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, 2 CFR Part 200 et seq ➢ Federal Funding Accountability and Transparency Act of 2006 ("FFATA") (Pub L 109-282, as amended by Section 6205(a) of Pub L 110-252 and Section 3 of Pub L 113-101) ➢ Federal Whistleblower Regulations, as contained in 10 U.S.C. 2409, 41 U.S.C. 4712, 10 U.S.C. 2324, 41 U.S.C. 4304 and 41 U.S.C. 4310. 14.11 HUD -Assisted Proiects and Employment and other Economic Opportunities; Section 3 Requirements. 14.11.1 Requirement that Law Be Ouoted in Covered Contracts. — Certain Requirements Pertaining to Section 3 of the Housing and Urban Development Act of 1968 as Amended (12 U.S.C. Sections 1701 et seq.) and its Related Regulations at 24 CFR Part 135. If the Program results in the creation of new employment, training, or contracting opportunities on a contractor or subcontractor level resulting from the expenditure of the HOPWA Funds, Agency shall comply with the following and will ensure that its contractors also comply If the work perfoitned under this Contract is on a project assisted under a program providing direct federal financial assistance from HUD, Section 3 of 24 CFR Part 135.38 ("Section 3') requires that the following clause, shown in italics, be inserted in all covered contracts ("Section 3 Clause"): Section to be quoted in covered contracts begins: "A. The work to be performed under this contract is subject to the requirements of Section 3 of Housing and Urban Development Act of 1968, as amended, 12 U.S.C. section 1701u (Section 3). The purpose of Section 3 is to ensure that employment and other economic opportunities generated by HUD assisted or HUD -assisted programs covered by Section 3, shall to the greatest extent feasible, be directed to low- and very -low income persons, particularly persons who are recipients of HUD assistance for housing. B. The parties to this contract agree to comply with HUD's regulations in 24 CFR Part 135, which implement Section 3. As evidenced by their execution of this contract, the parties to this contract cert0) that they are under no contractual or other impediment that would prevent them from complying with the Part 135 regulations. C. The contractor agrees to send to each labor organization or representative of workers with which it has a collective bargaining agreement or other understanding, if any, a notice advising the labor organization or workers' representatives of the contractor's commitments under this Section 3 clause and will post copies of the notice in conspicuous places at the work site where both employees and applicants for training and employment positions can see the notice. HOPWA PSA CONTRACT 2015-2016 Page 20 Tarrant County Samaritan House, Inc. Rev. 10 02 2015 The notice shall describe the Section 3 preference, shall set forth minimum number and job titles subject to hire, availability of apprentice and training positions, the qualifications for each; and the name and location of the person(s) taking applications for each of the positions; and the anticipated date the work shall begin. D. The contractor agrees that it will include this Section 3 clause in every subcontract to comply with regulation in 24 CFR Part 135, and agrees to take appropriate action, as provided in an applicable provision of the subcontract or in this Section 3 clause, upon finding that the subcontractor is in violation of the regulations in 24 CFR Part 135. The contractor will not subcontract with any subcontractor where it has notice or knowledge that the subcontractor has been found in violation of regulations in 24 CFR Part 135. E. The contractor will certi that any vacant employment positions, including training positions that are filed: (1) after the contractor is selected but before the contract is executed, and (2) with persons other than those to whom the regulations of 24 CFR Part 135. The contractor will not subcontract with any subcontractor where it has notice or knowledge that the subcontractor has been found in violation of regulations in 24 CFR Part 135. F. Noncompliance with HUD's regulation in 24 CFR Part 135 may result in sanctions, termination of this contract for default, and debarment or suspension from future HUD assisted contracts. G. With respect to work performed in connection with Section 3 covered Indian housing assistance, section 7(b) of the Indian Self -Determination and Education Assistance Act (25 U.S.C. Section 450(e) also applies to the work to be performed under this Contract. Section 7(b) requires that to the greatest extent feasible (i) preference and opportunities for training and employment shall be given to Indians, and (ii) preference in the award of contracts and subcontracts shall be given to Indian organizations and Indian -owned Economic Enterprises. Parties to this contract that are subject to the provisions of Section 3 and Section 7(b) agree to comply with Section 3 to the maximum extent feasible, but not in derogation of compliance with Section 7(b). " Section to be quoted in covered contracts ends. 14.11.2 Aaencv Responsibilities for Section 3 Requirements. City and Agency understand and agree that compliance with the provisions of Section 3, the regulations set forth in 24 CFR Part 135, and all applicable rules and orders of HUD shall be a condition of the federal financial assistance provided to the Program binding upon City and Agency and their respective successors, assigns, contractors and subcontractors. Failure to fulfill these requirements shall subject Agency and its contractors and subcontractors and their respective successors and assigns to those sanctions specified by the grant agreement through which federal assistance is provided and to such sanctions as are specified by 24 CFR Part 135. Agency's responsibilities include: 14.11.2.1 Implementing procedures to notify Section 3 residents and business concerns about training, employment, and contracting opportunities generated by Section 3 covered assistance; HOPWA PSA CONTRACT 2015-2016 Tan ant County Samai itan House, Inc. Page 21 Rev. 10 02 2015 14.11.2.2 Notifying potential contractors working on Section 3 covered projects of their responsibilities; 14.11.2.3 Facilitating the training and employment of Section 3 residents and the award of contracts to Section 3 business concerns; 14.11.2.4 Assisting and actively cooperating with the HED Department in making contractors and subcontractors comply; 14.11.2.5 Refraining from entering into contracts with contractors that are in violation of Section 3 regulations; 14.11.2.6 Documenting actions taken to comply with Section 3; and 14.11.2.7 Submitting Section 3 Annual Summary Reports (Fond HUD-60002) in accordance with 24 CFR Part 135.90. 14.11.3 Section 3 Reporting Requirements. In order to comply with the Section 3 requirements, Agency must submit the foil is attached hereto as EXHIBIT "G" - Section 3 Reporting Forms. 14.11.3.1 Report to the City on a quarterly basis all applicants for employment and all applicants for employment by contractor and subcontractor. This shall include name, address, zip code, date of application, and status (hired/not hired) as of the date of the report. 14.11.3.2 Advertise available positions to the public for open competition, and provide documentation to City with the quarterly report that demonstrates such open advertisement in the form of printout of Texas Workforce Commission posting, copy of newspaper advertisement, copy of flyers and listing of locations where flyers were distributed, and the like. 14.11.3.3 Report to the City on a quarterly basis all contracts awarded by contractor and subcontractor. This shall include name of contractor and/or subcontractor, address, zip code, and amount of award as of the date of the report. 14.12 Prohibition Against Discrimination. 14.12.1 General Statement. Agency shall comply in the execution, performance or attempted performance of this Contract with all non-discrimination requirements of 24 CFR Part 574.603 and Chaptei 17, Article III, Division 4 — Fair Housing of the City Code. Agency may not discriminate against any person because of race, color, sex, gender, religion, national origin, familial status, disability or HOPWA PSA CONTRACT 2015-2016 Page 22 Tan ant County Samaritan House, Inc. Rev. 10.02.2015 perceived disability, sexual orientation, gender identity, gender expression, or transgender, nor will Agency peiruiit its officers, members, agents, employees, or clients to engage in such discrimination This Contract is made and entered into with reference specifically to Chapter 17, Article III, Division 3 - Employment Practices of the City Code, and Agency hereby covenants and agrees that Agency, its officers, members, agents, employees and contractors, have fully complied with all provisions of same and that no employee, or applicant for employment has been discriminated against under the terms of such ordinances by either or its officers, members, agents, employees or contractors. 14.12.2 No Discrimination in Employment during the Performance of This Contract. During the performance of this Contract Agency agrees to the following provision, and will require that its contractors and subcontractors also comply with such provision by including it in all contracts with its contractors: [Contractor's, Subcontractor's or Vendor's name] will not unlawfully discriminate against any employee or applicants for employment because of race, color, sex, gender, religion, national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression or transgender. [Contractor's, Subcontractor's or Vendor's name]will take affirmative action to ensure that applicants are hired without regard to race, color, sex, gender, religion, national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression or transgender and that employees are treated fairly during employment without regard to their race, color, sex, gender, religion, national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression or transgender. Such action shall include, but not be limited to, the following: employment, upgrading, demotion or transfer, recruitment or recruitment advertising, layoff or termination, rates of pay or other founts of compensation, and selection for training, including apprenticeship [Contractor's, Subcontractor s or Vendor's name] agrees to post in conspicuous places available to employees and applicants for employment, notices setting forth the provisions of this nondiscrimination clause. [Contractor's Subcontractor's or Vendor's namel will, in all solicitations or advertisements for employees placed by or on behalf of [Contractor's, Subcontractor's or Vendor's name], state that all qualified applicants will receive consideration for employment without regard to race, color sex, gender, religion, national origin, familial status, disability or perceived disability, sexual orientation, gender identity, gender expression or transgender. [Contractor's, Subcontractor's or Vendor's name] covenants that neither it nor any of its officers members, agents employees, or contractors, while engaged in performing this Contract, shall, in connection with the employment, advancement or discharge of employees or in connection with the terms, conditions or privileges of their employment, discriminate against persons because of their age of because of any disability or perceived disability, except on the basis of a bona fide occupational qualification, retirement plan or statutory requirement. HOPWA PSA CONTRACT 2015-2016 Page 23 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 [Contractor's, Subcontractor's or Vendor's name] further covenants that neither it nor its officers members, agents, employees, contractors, or persons acting on their behalf, shall specify, in solicitations or advertisements for employees to work on this Contract, a maximum age limit for such employment unless the specified maximum age limit is based upon a bona fide occupational qualification, retirement plan or statutory requirement. 14.12.3 Agency's Contractors and the ADA. In accordance with the provisions of the Americans With Disabilities Act of 1990 ( `ADA"), Agency warrants that it and any of its contractors will not unlawfully discriminate on the basis of disability in the provision of services to the general public, nor in the availability, teruns and/or conditions of employment for applicants for employment with, or employees of, Agency or any of its contractors. AGENCY WARRANTS IT WILL FULLY COMPLY WITH THE ADA'S PROVISIONS AND ANY OTHER APPLICABLE FEDERAL, STATE AND LOCAL LAWS CONCERNING DISABILITY AND WILL DEFEND, INDEMNIFY AND HOLD CITY HARMLESS AGAINST ANY CLAIMS OR ALLEGATIONS ASSERTED BY THIRD PARTIES CONTRACTORS SUBCONTRACTORS, VENDORS OR AGENTS AGAINST CITY ARISING OUT OF AGENCY'S AND/OR ITS CONTRACTORS', SUBCONTRACTORS', VENDORS' OR AGENTS' OR THEIR RESPECTIVE EMPLOYEES' ALLEGED FAILURE TO COMPLY WITH THE ABOVE -REFERENCED LAWS CONCERNING DISABILITY DISCRIMINATION IN THE PERFORMANCE OF THIS CONTRACT. 14.13. Conflicts of Interest and Violations of Criminal Law. 14.13.1 Aaencv Safeguards. Agency shall establish safeguards to prohibit its employees, board members, advisors and agents from using positions for a purpose that is or gives the appearance of being motivated by a desire for private gain for themselves or others particularly those with whom they have family, business or other ties. Agency shall disclose to City any such conflict of interest or potential conflict of interest, immediately upon discovery of such 14.13.2 General Prohibitions Against Conflicts of Interest. No employees, agents, consultants, officers or elected officials or appointed officials of City or of Agency who exercise or have exercised any functions or responsibilities with respect to activities assisted with HOPWA funds or who are in a position to participate in a decision -making process or gain inside information with regard to these activities may utilize HOPWA services, may obtain a financial interest or benefit from a HOPWA-assisted activity, or have an interest in any contract, subcontract or agreement with respect thereto, or the proceeds thereunder, either for themselves or those with whom they have family or business ties, during their tenure or for 1 year thereafter, unless they are accepted in accordance with the procedures set forth at 24 CFR Part 574.625. 14.13.2.1 Agency shall establish conflict of interest policies for federal awards including the CDBG Funds and shall disclose in writing potential conflicts of interest to City as authorized by 2 CFR Part 200.112. HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc Page 24 Rev. 10 02 2015 14.13.3 Conflicts of Interest Involving Procurement. The conflict of interest provisions of 24 CFR Part 85.36 and 24 CFR Part 84.42, respectively, shall apply in the procurement of property and services by Agency. In all cases not governed by those Sections, the provisions of 24 CFR Part 574.625 of the HOPWA Regulations shall apply. 14.13.3.1 As more particularly described in 2 CFR Part 200.318, Agency shall maintain and submit to City written standards of conduct covering conflicts of interest and governing the perfoiivance of its employees engaged in the selection, award, and administration of contracts. No employee, officer, or agent may participate in the selection, award, or administration of a contract supported by a federal award if he or she has a real or apparent conflict of interest. The standards of conduct must provide for disciplinary actions to be applied for violations of such standards by officers, employees, or agents of Agency. 14.13.3.2 The officers, employees, and agents of Agency shall neither solicit nor accept gratuities, favors, or anything of monetary value from contractors or parties to subcontracts. 14.13.3.3 Notwithstanding the prohibition contained in Section 14.13.3.2, Agency may set standards of conduct for situations in which the financial interest is not substantial or the gift is an unsolicited item of nominal value. Such standards of conduct must provide for disciplinary actions to be applied for violations of such standards by Agency's officers, employees or agents 14.13.3.4 Agency shall maintain written standards of conduct covering organizational conflicts of interest. Organizational conflicts of interest means that because of relationships with a parent company, affiliate, or subsidiary organization, Agency is unable or appears to be unable to be impartial in conducting a procurement action involving a related organization. 14.13.3.5 Agency must maintain records sufficient to detail the history of procurement These records will include, but ale not necessarily limited to the following: rationale for the method of procurement, selection of contract type, contractor selection or rejection, and the basis for the contract price. 14.13.4 Disclosure of Conflicts of Interest. In compliance with 2 CFR Part 200.112, Agency is required to timely disclose to City in writing any potential conflict of interest. 14.13.5 Disclosure of Texas Penal Code Violations. Agency affirms that it will adhere to the provisions of the Texas Penal Code which prohibit bribery and gifts to public servants. HOPWA PSA CONTRACT 2015-2016 Page 25 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 14.13.6 Disclosure of Federal Criminal Law Violations. In compliance with 2 CFR Part 200.113, Agency is required to timely disclose to City all violations of federal criminal law involving fraud, bribery or gratuity violations potentially affecting the Agency. 14.14 Subcontracting with Small and Minority Firms. Women's Business Enterprises and Labor Surplus Areas. 14.14 1 For piocurement contracts $50,000.00 or larger that are paid for, in part or in full, with HOPWA Funds, Agency agrees to abide by City's policy to involve Minority Business Enterprises and Small Business Enterprises and to provide them equal opportunity to compete for contracts for construction, provision of professional services, purchase of equipment and supplies and provision of other services required by City. Agency agrees to incorporate the City's BD1-1, Ordinance, and all amendments or successor policies or ordinances thereto into all contracts and subcontracts for piocurement larger than $50 000 00 or larger that are paid for, in part or in full, with the HOPWA Funds and will further require all persons or entities with which it so contracts to comply with said ordinance. 14.14.2 It is national policy to award a fair share of contracts to disadvantaged business enterprises ("DBEs"), small business enterprises ("SBEs"), minority business enterprises ("MBEs"), and women s business enterprises ("WBEs"). Accordingly, affirmative steps must be taken to assure that DBEs, SBEs, MBEs, and WBEs are utilized when possible as sources of supplies, equipment, construction and services. 14.14.2.1 In order to comply with federal reporting requirements, Agency must submit the form attached hereto as EXHIBIT "I" — MBE Reporting Form for each contract or subcontract with a value of $10,000.00 or more paid or to be paid with the HOPWA Funds. Agency shall submit this form by the date specified in EXHIBIT "I" — MBE Reporting Form 14.15 Other Laws. The failure to list any federal, state or City ordinance, law or regulation that is applicable to Agency does not excuse or relieve Agency from the requirements or responsibilities in regard to following the law, nor from the consequences or penalties for Agency's failure to follow the law, if applicable. 14.16 Assignment. Agency shall not assign all or any part of its rights, privileges, or duties under this Contract without the prior written approval of City. Any attempted assignment of same without approval shall be void, and shall constitute a breach of this Contract. 14.17. Right to Inspect Agency Contracts It is agreed that City has the right to inspect and approve in writing any proposed contracts between Agency and any contractor or vendor engaged in any activity in conjunction with this HOPWA-funded Program prior to any charges being incurred. HOPWA PSA CONTRACT 2015-2016 Page 26 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 14.18 Force Maieure If Agency becomes unable, either in whole or part, to fulfill its obligations under this Contract due to acts of God, spikes, lockouts, or other industrial disturbances, acts of public enemies, wars, blockades, insurrections, riots, epidemics, earthquakes, fires, floods, restraints or prohibitions by any court, board, department, commission or agency of the United States or of any States, civil disturbances, or explosions, or some other reason beyond Agency's control (collectively, "Force Majeure Event"), the obligations so affected by such Force Majeure Event will be suspended only during the continuance of such event Agency will give City written notice of the existence, extent and nature of the Force Majeure Event as soon as reasonably possible after the occurrence of the event. Failure to give notice will result in the continuance of Agency's obligation regardless of the extent of any existing Force Majeure Event Agency will use commercially reasonable efforts to remedy its inability to perform as soon as possible. 15. INDEMNIFICATION AND RELEASE. AGENCY COVENANTS AND AGREES TO INDEMNIFY, HOLD HARMLESS AND DEFEND, AT ITS OWN EXPENSE, CITY AND ITS OFFICERS, AGENTS, SERVANTS AND EMPLOYEES FROM AND AGAINST ANY AND ALL CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER KIND OR CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS, ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER OR NOT CAUSED IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY; AND AGENCY HEREBY ASSUMES ALL LIABILITY AND RESPONSIBILITY OF CITY AND ITS OFFICERS, AGENTS, SERVANTS, AND EMPLOYEES FOR ANY AND ALL CLAIMS OR SUITS FOR PROPERTY LOSS OR DAMAGE AND/OR PERSONAL INJURY, INCLUDING DEATH, TO ANY AND ALL PERSONS, OF WHATSOEVER KINDS OR CHARACTER, WHETHER REAL OR ASSERTED, ARISING OUT OF OR IN CONNECTION WITH THE EXECUTION, PERFORMANCE, ATTEMPTED PERFORMANCE OR NONPERFORMANCE OF THIS CONTRACT AND/OR THE OPERATIONS, ACTIVITIES AND SERVICES OF THE PROGRAM DESCRIBED HEREIN, WHETHER OR NOT CAUSED IN WHOLE OR IN PART BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY. AGENCY LIKEWISE COVENANTS AND AGREES TO AND DOES HEREBY INDEMNIFY AND HOLD HARMLESS CITY FROM AND AGAINST ANY AND ALL INJURY, DAMAGE OR DESTRUCTION OF PROPERTY OF CITY, ARISING OUT OF OR IN CONNECTION WITH ALL ACTS OR OMISSIONS OF AGENCY, ITS OFFICERS, MEMBERS, AGENTS, EMPLOYEES, CONTRACTORS, SUBCONTRACTORS, INVITEES, LICENSEES, OR CLIENTS, OR CAUSED, IN WHOLE OR IN PART, BY ALLEGED NEGLIGENCE OF OFFICERS, AGENTS, SERVANTS, EMPLOYEES, CONTRACTORS OR SUBCONTRACTORS OF CITY. HOPWA PSA CONTRACT 2015-2016 Page 27 Tarrant County Samaritan House, Inc Rev. 10.02.2015 IT IS THE EXPRESS INTENTION OF THE PARTIES, BOTH AGENCY AND CITY, THAT THE INDEMNITY PROVIDED FOR THIS SECTION INCLUDES INDEMNITY BY AGENCY TO INDEMNIFY AND PROTECT CITY FROM THE CONSEQUENCES OF CITY'S OWN NEGLIGENCE, WHETHER THAT NEGLIGENCE IS ALLEGED TO BE THE SOLE OR CONCURRING CAUSE OF THE INJURY, DAMAGE OR DEATH. AGENCY AGREES TO AND SHALL RELEASE CITY, ITS AGENTS, EMPLOYEES, OFFICERS AND LEGAL REPRESENTATIVES FROM ALL LIABILITY FOR INJURY, DEATH, DAMAGE OR LOSS TO PERSONS OR PROPERTY SUSTAINED IN CONNECTION WITH OR INCIDENTAL TO PERFORMANCE UNDER THIS CONTRACT, EVEN IF THE INJURY, DEATH, DAMAGE OR LOSS IS CAUSED BY CITY'S SOLE OR CONCURRENT NEGLIGENCE. AGENCY SHALL REQUIRE ALL OF ITS CONTRACTORS AND SUBCONTRACTORS TO INCLUDE IN THEIR CONTRACTS AND SUBCONTRACTS A RELEASE AND INDEMNITY IN FAVOR OF CITY IN SUBSTANTIALLY THE SAME FORM AS ABOVE 16. WAIVER OF IMMUNITY BY AGENCY. If Agency, as a charitable or nonprofit organization, has or claims an immunity or exemption (statutory or otherwise) from and against liability for damages or injury, including death to persons or property, Agency hereby expressly waives its rights to plead defensively such immunity or exemption as against City. This Section shall not be construed to affect a governmental entity s immunities under constitutional, statutory or common law. 17. INSURANCE AND BONDING. Agency will maintain coverage in the form of insurance or bond in the amount of $420,063.00 to insure against loss from the fiaud, theft or dishonesty of any of Agency's officers, agents, trustees, directors or employees. The proceeds of such insurance or bond shall be used to reimburse City for any and all loss of HOPWA Funds occasioned by such misconduct. To effectuate such reimbursement, such fidelity coverage shall include a rider stating that reimbursement for any loss or losses shall name the City as a Loss Payee. Agency shall furnish to City in a timely manner, but not later than the Effective Date, certificates of insurance as proof that it has secured and paid for policies of commercial insurance as specified herein If City has not received such certificates by the Effective Date, Agency shall be in default of the Contract and City may, at its option, terminate the Conti act. Such insurance shall cover all insurable risks incident to or in connection with the execution, performance, attempted perfournance or nonperformance of this Contract. Agency shall maintain the following insurance coverage and limits: Commercial General Liability (CGL) Insurance $ 500,000 each occurrence $1,000,000 aggregate limit HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Page 28 Rev. 10 02 2015 Non -Profit Organization Liability or Directors & Officers Liability $1,000,000 Each Occurrence $1,000,000 Annual Aggregate Limit Business Automobile Liability Insurance $1,000,000 each accident on a combined single -limit basis, or $ 250,000 Property Damage $ 500,000 Bodily Injury per person per occurrence $2,000,000 Aggregate Insurance policy shall be endorsed to cover "Any Auto", defined as autos owned, hired, and non -owned. Pending availability of the above coverage and at the discretion of City, the policy shall be the primary responding insurance policy versus a personal auto insurance policy if or when in the course of Agency's business as contracted herein. Workers' Compensation Insurance Part A: Statutory Limits Part B: Employer's Liability $100,000 each accident $100,000 disease -each employee $500,000 disease -policy limit Note: Such insurance shall cover employees perfouuing work on any and all projects including but not limited to construction, demolition, and rehabilitation. Agency or its contractors shall maintain coverages, if apphcable In the event the respective contractors do not maintain coverage Agency shall maintain the coverage on such contractor, if applicable, for each applicable contract. Additional Requirements Such insurance amounts shall be revised upward at City's reasonable option and no more frequently than once every 12 months, and Agency shall revise such amounts within 30 days following notice to Contractor of such requirements Agency will submit to City documentation that it has obtained insurance coverage and has executed bonds as required in this Contract prior to payment of any monies provided hereunder. Where applicable, insurance policies required herein shall be endorsed to include City as an additional insured as its interest may appear. Additional insured parties shall include employees, officers, agents, and volunteers of City. Any failure on part of City to request certificate(s) of insurance shall not be construed as a waiver of such requirement or as a waiver of the insurance requirements themselves. HOPWA PSA CONTRACT 2015-2016 Page 29 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 Insurers of Agency's insurance policies shall be licensed to do business in the state of Texas by the Department of Insurance or be otherwise eligible and authorized to do business in the state of Texas. Insurers shall be acceptable to City insofar as their financial strength and solvency and each such company shall have a current minimum A.M. Best Key Rating Guide rating of A-: VII or other equivalent insurance industry standard rating otherwise approved by City. Deductible limits on insurance policies shall not exceed $5,000 per occurrence unless otherwise approved by City. In the event there are any local, federal or other regulatory insurance or bonding requirements for the Program, and such requirements exceed those specified herein, the former shall prevail. Agency shall require its contractors to maintain applicable insurance coverages, limits, and other requirements as those specified herein; and Agency shall require its contractors to provide Agency with certificate(s) of insurance documenting such coverage. Also, Agency shall require its contractors to have City and Agency endorsed as additional insureds (as their interest may appear) on their respective insurance policies. Directors and Officers Liability coverage shall be in force and may be provided on a claims -made basis. This coverage may also be referred to as Management Liability, and shall protect the insured against claims arising out of alleged errors in judgment, breaches of duty and wrongful acts arising out of their organizational duties. Coverage shall protect not only the entity, but all past, present and future directors, officers, trustees, employees, volunteers and committee members. Notwithstanding any provision in this Contract to the contrary, when applicable, Agency shall comply with the requirements of 2 CFR 200.310 and shall, at a minimum, provide the equivalent insurance coverage for real property and equipment acquired or improved with CDBG Funds as provided to property owned by Agency. 18. CERTIFICATION REGARDING LOBBYING. The undersigned representative of Agency hereby certifies, to the best of his or her knowledge and belief, that: No federal appropriated funds have been paid or will be paid, by or on behalf of Agency, to any person for influencing or attempting to influence an officer or employee of any agency, a member of Congress an offices or employee of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement and the extension, continuation, renewal, amendment, or modification of any federal contract, grant, loan or cooperative agreement. If any funds other than federally appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, member of Congress in connection with this federal contract, grant, loan or cooperative HOPWA PSA CONTRACT 2015-2016 Page 30 Tarrant County Samaritan House, Inc. Rev. 10.02.2015 agreement, Agency shall complete and submit Standard Form-LLL, "Disclosure Form to Report Lobbying," in accordance with its instructions. This certification is a material representation of fact upon which reliance was placed when this Contract was made or entered into. Submission of this certificate is a prerequisite for making or entering into this Contract imposed by 31 U.S.C. Section 1352. Any person who fails to file the required certification shall be subject to a civil penalty of not less than $10,000.00 and not more than $100,000 00 for each such failure Agency shall require that the language of this certification be included in all subcontracts or agreements involving the expenditure of federal funds 19. LITIGATION AND CLAIMS. Agency shall give City immediate notice in writing of any action, including any proceeding before an administrative agency, filed against Agency in conjunction with this Contract or the Program. Agency shall furnish immediately to City copies of all pertinent papers received by Agency with respect to such action or claim. Agency shall provide a notice to City within 10 days upon filing under any bankruptcy or financial insolvency provision of law. 20. NOTICE All notices required or permitted by this Contract must be in writing and are deemed delivered on the earlier date of the date actually received or the third day following deposit in a United States Postal Service post office or receptacle; with proper postage, certified mail return receipt requested; and addressed to the other Party at the address set out below or at such other address as the receiving Party designates by proper notice to the sending Party. City: City Attorney's Office 1000 Throckmorton Street Fort Worth, TX 76102 Telephone: 817-3 92-76 00 Copy to: Director of Neighborhood Services Department 1000 Throckmorton Street Fort Worth, TX 76102 Attention: Assistant Director Telephone• 817-392-7540 Copy to: Director of Neighborhood Services Department 1000 Throckmorton Street Fort Worth, TX 76102 Attention: Program Coordinator Telephone: 817-392-6342 HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc Page 31 Rev. 10 02 2015 Agencv: Tarrant County Samaritan House, Inc Lyn Scott 929 Hemphill Street Fort Worth, TX 76104 Telephone: 817-332-6410 21. AGENCY HAS LEGAL AUTHORITY TO ENTER INTO CONTRACT. Agency represents that it possesses the legal authority, pursuant to any proper, appropriate and official motion, resolution or action passed or taken, to enter into this Contract and to perform the responsibilities herein required. 22. COUNTERPARTS. This Contract may be executed in multiple counterparts, each of which shall be considered an original, but all of which shall constitute one instrument which may be sufficiently evidenced by one counterpart. [SIGNATURES APPEAR ON NEXT PAGE] HOPWA PSA CONTRACT 2015-2016 Tan ant County Samaritan House, Inc. Page 31-1 Rev. 10.02.2015 IN WITNESS WHEREOF, the Parties hereto have executed 4 duplicate originals of this Contract in Fort Worth, Tarrant County, Texas. ATTEST: CITY OF FORT WORTH City Secretary M&C: G-18521 Date: August 4, 2015 By: APPROVED AS TO FORM AND LEGALITY: Assistant City Attorney HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Fernando Costa, Assistant City Manager TARRANT COUNTY SAMARITAN HOUSE, INC. By: Name: Title: Yia OFFICIAL RECORD CITY SECRETARY Ft WORTH, TX Page 32 Rev. 09.01.2015 IN WITNESS WHEREOF, t ,e Parties hereto have executed 4 duplicate originals of this Contract ee in Fort Worth, Tarrant C Ci y Sec dry M&C: -18521 Date: August 4, 2015 APPROVED AS TO FO Assistant City Attorney CITY OF FORT WORTH By: AND LEGALITY: HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc. Fernando Costa, Assistant City Manager TARRANT COUNTY SAMARITAN HOUSE, INC. By: Name: Norbert White Title: President/CEO OFFICIAL RECORD CITY SECRETARY Ft JYORTH, TX Page 32 Rev. 10.02.2015 EXHIBITS: EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT "A" — Program Summary "A-1" — 2015 HUD Income Limits "A-2" - Requirements for Completion of "Getting to Work Training Curriculum" "B" — Budget "C" — Audit Certification Form "D" — Reimbursement Forms "E" — Form of Income Self -Certification "F" — Standards for Complete Documentation "G" — Section 3 Reporting Forms "H" — Overview Report "I" — MBE Reporting Form HOPWA PSA CONTRACT 2015-2016 Tarrant County Samat itan House, Inc. Page 33 Rev. 10 02 2015 EXHIBITS: EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT EXHIBIT "A" — Program Summary "A-1" — 2015 HUD Income Limits "A-2" - Requirements for Completion of "Getting to Work Training Curriculum" "B" — Budget "C" — Audit Certification Form "D" — Reimbursement Forms "E" — Form of Income Self -Certification "F" — Standards for Complete Documentation "G" — Section 3 Reporting Forms "H" — Overview Report "I" — MBE Reporting Form HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc Page 33 Rev. 09.01.2015 TARRANT COUNTY SAMARITAN HOUSING, INC. EXHIBIT "A" Samaritan House Supportive Services PROGRAM SUMMARY PROGRAM SUMMARY (HOPWA) October 1, 2015 to September 30, 2016 PERIOD $420 063.00 AMOUNT Capitalized terms not defined herein shall have meanings assigned them in the Contract. PROGRAM: The Program provides supportive services to HOPWA Eligible Clients living in the Samaritan Villages Apartments, the Samaritan House Single Room Occupancy ("SRO") Facility, and in scattered -site rental -voucher supported housing. The supportive services include case management and housing counseling Program services may also include congregate meals; medical case management; substance abuse counseling; medical transportation; recreational and social programs; educational programs; and life and job skills programs. HOPWA Funds will be used to pay for a percentage of supportive service salaries, fringe benefits supplies, and contract labor associated with the Program. HOPWA Funds will also be used to pay for the operational expenses of the Agency's SRO Facility located at 929 Hemphill Street, Fort Worth, TX 76104. Operational expenses consist of but are not limited to salaries and fringe benefits for property management and maintenance staff. No more than 7% of the HOPWA Funds will be used to pay for administrative costs, including salaries and fringe benefits, City -required insurance, taxes, and legal/accounting fees associated with the Program. Agency's office and Program services will be available at 929 Hemphill Street, Fort Worth, Texas 76104, Monday through Friday, 9:00 a.m. to 5:00 p.m. Program services may also be provided at clients' homes. The SRO is staffed 24 hours a day, 7 days a week. The Program will be provided services to HOPWA Eligible clients residing in Tarrant, Johnson, Parker, Wise, Hood and Somervell counties. REGULATORY CLASSIFICATION: IDIS matrix Code(s) and Service Category: 31D HOPWA Project Sponsor Administration 31C HOPWA Project Sponsor Activity Regulatory Citation(s)• 24 CFR 574.300(b)(10) — Administrative Expenses 24 CFR 574.300(b)(7) — Supportive Services 24 CFR 574.300(b)(8) Facility Based Operations HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "A" — PROGRAM SUMMARY Page 1 Tarrant County Samaritan Housing, Inc. Agency will maintain documentation which verifies that 100% of clients served by the Program are eligible under HOPWA Regulations. PROGRAM GOALS: Minimum Number of Clients to be Served: The Program must provide Supportive Services to a minimum of 160 Unduplicated Clients. Unduplicated Clients must be a resident of Tarrant, Johnson, Parker, Wise, Hood and Somervell counties as shown by the monthly reports on Attachment III. The Program will also provide Facility Based Housing Subsidy Assistance through the housing operations of 60 household housing units. HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "A" — PROGRAM SUMMARY Page 2 Tarrant County Samaritan Housing, Inc. 30%AMI 50% AMI 80% AMI EXHIBIT "A-1" 2015 HUD INCOME LIMITS 2015 Median Family Income - Fort Worth/Arlington, TX* 1 Person 2 Persons $14,650 $16,750 $24,400 $27,900 $39,050 $44,600 3 Persons 4 Persons 5 Persons 6 Persons $20,090 $31,400 $50,200 $24,250 $34,850 $55,750 $28,410 $37,650 $60,250 $32,570 $40,450 $64,700 *Income limits are published at least annually by HUD. HOPWA PSA CONTRACT 2015-2016 -- EXHIBIT "A-1" — 2015 HUD INCOME LIMITS Tarrant County Samaritan Housing, Inc. 7 Persons $36,730 $43,250 $69,150 8 Persons $40,890 $46,050 $73,600 Page 1 EXHIBIT "A-2" REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING CURRICULUM" HOPWA PSA CONTRACT 2015-2016 Page 1 EXHIBIT "A-2" REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING CURRICULUM" Tarrant County Samaritan House Inc. Getting to Work: A Training Curriculum for HIV/AIDS Service Providers and Housing Providers At least 1 Agency employee must complete this required training curriculum by the deadline of April 15, 2016. Proof of completion must be submitted with the April reimbursement request. The Getting to Work Training Curriculum is divided into 3 online modules: Module 1: Understanding the Value of Work Module 2: Adopting an Employment and Training Mindset — Organizationally and Individually Module 3: Incorporating Employment into the HIV/AIDS Service Menu To view the modules• 1. Click the module title. 2. You will be prompted to either create or log into your HUD Exchange Learn account. 3. Follow this guidance when creating a HUD Exchange account: Step 1 of 2 screen: Fill out the required Personal Information, and Login Information sections. For the Organization Information, if you are not affiliated with a HUD program, choose None of the Above and I am an Individual. Step 2 of 2 screen: All HUD Program Experience fields on the Learner Profile page are optional. Click Update to complete the account creation process. 4. After creating an account or logging in, you will enter the HUD Exchange Learn system. 5. Click the Enroll button on the HUD Exchange Learn course description to access the course. 6. The module name will appear under Activities. Click the Module Name to access the course. 7. The module will launch in a new window, so please make sure your pop-up blockers are turned off. To receive credit for completing each module: 1. Take the completion quiz under Activities on the HUD hxchange Learn course description Each module has a quiz. 2. Score 80% or better on the quiz You may take the quiz multiple times. 3. After you pass the quiz, you will be able to print a completion certificate on the HUD Exchange Learn course description. You can access information about the modules by visiting the HUD Exchange website at www.hudexchange.com or by using the following link: https://www.hudexchange.info/training-events/dol- hud-getting-to-work-curriculum-for-hiv-aids-providers. You may also contact your assigned contract administrator to get additional information. HOPWA PSA CONTRACT 2015-2016 Page 2 EXHIBIT "A-2" REQUIREMENTS FOR COMPLETION OF "GETTING TO WORK TRAINING CURRICULUM" Tarrant County Samaritan House Inc Salaries FICA Life Insurance Health Insurance Disability Insurance Unemployment -State Workers Compensation Contract Labor - Accounting TOTAL ADMINISTRATIVE EXPENSES PROGRAM PERSONNEL Salaries FICA EXHIBIT `B" - BUDGET Account Grant I A (Tarrant III Budget I County) ADMINISTRATIVE (HOPWA ONLY) Life Insurance Health Insurance Unemployment Worker's Compensation Retirement SUPPLIES AND SERVICES Office Supplies Office Equipment Rental Postage Printing MISCELLANEOUS Construction/Building Materials (only REACH) Contract Labor - Accounting & IT (City needs copy of contract before expenses can be reimbursed) Craft Supplies Field Trip Admission Expenses Other Field Trip Expenses (if preapproved by City) Food Supplies Teaching Aids FACILITY AND UTILITIES Telephone Electric Gas Water and Wastewater Solid Waste Disposal Rent (City needs copy of lease before expenses can be reimbursed) Custodial Services Repairs Cleaning Supplies Building Security LEGAL, FINANCIAL, AND INSURANCE Fidelity Bond or Equivalent Directors and Officers General Commercial Liability Contract Accounting Audit Fees TOTAL SUPPORTIVE SERVICE EXPENSES DIRECT ASSISTANCE Childcare Scholarships DIRECT ASSISTANCE - STRMU Short-term Rent Assistance 1001 1002 1003 1004 1005 1006 1007 1008 16,195 1,239 12 1,509 34,880 2,668 348 4,186 0 0 324 1,046 69 151 0 0 19,348 43,279 4.6% SUPPORTIVE SERVICE 2001 2002 2003 2004 2005 2006 2007 3001 3002 3003 3004 4001 4002 4003 4004 4005 4006 4007 5001 5002 5003 5004 5005 5006 5007 5008 5009 5010 6001 6002 6003 6004 6005 7001 7002 225,419 17,245 318 38,843 4,508 5,467 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 500 0 0 806 1,500 294,606 0 0 225,735 17,269 312 38,897 451 5,475 0 3,979 2,400 500 500 0 7,959 0 0 0 91,500 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 394,977 0 0 B (Pnvate Funding) 317,249 24,270 3,178 38,070 0 9,517 1,372 0 393,656 151,559 11,594 209 26,116 3,031 3,676 0 1,021 2,400 2,500 4,500 0 22,041 0 0 0 0 0 6,000 12,000 0 1,200 1,200 0 11,300 6,000 1,200 0 0 1,700 32,400 0 10,000 311,647 0 0 C TOTAL 368,324 28,177 3,538 43,765 0 10,887 1,592 0 456,283 602,713 46,108 839 103,856 7,990 14,618 0 5,000 4,800 3,000 5,000 0 30,000 0 0 0 91,500 0 6,000 12,000 0 1,200 1,200 0 11,300 6,000 1,200 0 500 1,700 32,400 806 11,500 1,001,230 0 0 HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc EXHIBIT `B" - BUDGET Page 1 Short-term Mortgage Assistance Short-term Utilities Assistance TOTAL STRMU EXPENSES DIRECT ASSISTANCE - TBRA Tenant Based Rental Assistance TOTAL TBRA EXPENSES FACILITY BASED OPERATION EXPENSES Salaries FICA Life Insurance Health Insurance Disability Insurance Unemployment - State Worker's Compensation Accounting Retirement Insurance - Commercial Property and Liability, Professional Liability TOTAL FACILITY BASED OPERATION EXPENSES BUDGET TOTAL FUNDING A: TARRANT COUNTY FUNDING B: PRIVATE FUNDING FUNDING C: 7003 7004 7005 8001 8002 8003 8004 8005 8006 8007 8008 8009 8010 0 0 0 0 0 86,433 6,612 170 8,445 0 1,729 2,720 0 0 0 0 0 0 232,659 232,659 87,759 6,714 172 8,575 0 1,755 2,762 0 0 0 106,109 107,737 420,063 778,652 0 0 0 0 0 57,736 4,417 113 5,641 0 1,155 1,817 0 0 0 70,879 776,182 0 0 0 232,659 232,269 231,928 17,743 455 22,661 0 4,639 7,299 0 0 0 284,725 1,974,897 HOPWA PSA CONTRACT 2015-2016 - EXHIBIT "B" - BUDGET Tarrant County Samaritan House, Inc. Page 2 The following tables were created for the purpose of preparing, negotiating, and determining the cost reasonableness and cost allocation method used by the Agency for the line item budget represented on the first page of this EXHIBIT 'B" - Budget. The information reflected in the tables is to be considered part of the terms and conditions of the Contract. Agency must have prior written approval by the City to make changes to any line item in the Budget as outlined in Section 5.2.2 in the Contract. The deadline to make changes to EXHIBIT "B' - Budget is June 1, 2016. Position Name President/Chief Executive Officer Vice President and Chief Operations Officer Administrative Assistant - Accounting Grant Manager TOTAL FICA Life Insurance Health Insurance Disability Insurance Unemployment Workers Comp TOTAL Contract Labor - Accounting TOTAL SALARY DETAIL - ADMINISTRATIVE Rate 106,624 87,837 23,673 42,271 260,405 Annual Hours Percent to Grant Amount to Grant 2080 4% 4,265 FRINGE DETAIL Percent of Payroll 7.65% .076% 11% 0% 2% 0.4324% 2080 2080 2080 8% 7,027 10% 2,367 6% 6.2% - ADMINISTRATIVE Amount 19,921 198 27,552 0 5,208 1,126 54,005 Percent to Grant 6.22% 6.06% 5.477% 0% 6.22% 6.13% 5.8% MISCELLANEOUS - ADMINISTRATIVE Total Budget Percent to Grant SALARY DETAIL - SUPPORTIVE SERVICES Position Name Vice President and Chief Program Officer Food Service Manager Cook 1 Cook 2 Cook 3 Medical Case Manager Resident Care Coordinator Resident Care Attendant 1 (RCA 1) Resident Care Attendant 2 (RCA 2) Resident Care Attendant 3 (RCA Rate 77,490 43,037 30,638 30,784 13,530 62,400 31,364 24,960 22,880 11,440 Annual Hours 2080 2080 2080 2080 1333 2080 2080 2080 2080 1040 Percent to Grant 17% 27% 55% 56% 53% 17% 34% 55% 61% 58% 2,536 16,195 Amount to Grant 1,239 12 1,509 0 324 69 3,153 Amount to Grant 0 0 Amount to Grant 13,173 11,620 16,851 17,239 7,171 10,608 10,664 13,728 13,957 6,635 HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan House, Inc EXHIBIT "B" - BUDGET Page 3 3) Resident Care Attendant 4 (RCA 4) Resident Care Attendant 5 (RCA 5) Family Health and Education Manager Case Management Program Manager/LCDC Support Services Manager Social Services Case Manager 1 Social Services Case Manager 2 TOTAL FICA Life Insurance Health Insurance Unemployment Disability Insurance Workers Compensation Retirement TOTAL 11,440 5,720 47,000 42,000 39,690 40,000 37,500 571,873 1040 520 2080 2080 2080 2080 2080 65% 56% 31% 39.4% FRINGE DETAIL - SUPPORTIVE SERVICES Percent of Payroll 7.65% .1384% 15.2177% 2% 2.214% Amount 43,748 792 87,026 11,437 0 12,662 0 159,665 Percent to Grant 39.42% 40% 44.634% 39.42% 43.18% 41.5% FACILITY BASED OPERATION SALARY DETAIL Position Name Driver/Maintenance Manager Property Manager Administrative Assistant - Property Support Driver/Maintenance Technician TOTAL FICA Life Insurance Health Insurance Disability Insurance Unemployment -State Worker's Compensation Retii ement Accounting TOTAL Rate 38,081 48,830 20,800 18,720 126,431 Annual Hours 2080 2080 2080 2080 FACILITY BASED OPERATION FRINGE Percent of Payroll 7.65% .0462% 2.9144% 0% .4422% .7058% 0% 0% DETAIL Amount 9,672 264 16,667 0 2,529 4,036 0 0 33,168 FACILITY BASED OPERATION INSURANCE Total Budget Commercial Property and Liability, Professional Liability TOTAL 22,778 Percent to Grant 60% 86% 30% 82% 68.3% 6,978 5,091 27,260 4,620 25,799 22,400 11,625 225,419 Amount to Grant Percent to Grant 68.36% 64.44% 50.67% 0% 68.37 67.39% 0% 0% 59.3% Percent to Grant 0% 17,245 318 38,843 4,508 0 5,467 0 66,381 Amount to Grant 22,849 41,994 6,240 15,350 86,433 Amount to Grant 6,612 170 8,445 0 1,729 2,720 0 0 19,676 Amount to Grant 0 0 HOPWA PSA CONTRACT 2015-2016 - EXHIBIT "B" - BUDGET Tarrant County Samai itan House, Inc. Page 4 SUPPLIES AND SERVICES - SUPPORTIVE SERVICES Office Supplies Office Equipment Rental Postage Printing Medical Supplies TOTAL Contract Labor — IT Contract Labor — Accounting Craft Supplies Facility Fees Field Trip Costs Food Supplies Teaching Aids TOTAL Total Budget 5,000 8,111 3,000 10,067 8,250 34,428 Percent to Grant 0% 0% 0% 0% 0% MISCELLANEOUS - SUPPORTIVE SERVICES Total Budget Percent to Grant 0 37,000 0% 0 0 0 95,000 I 0% 0 132,000 FACILITY AND UTILITIES - SUPPORTIVE SERVICES Telephone Electric Gas Water and Wastewater Solid Waste Disposal Rent Custodial Services Repairs Cleaning Supplies Building Security TOTAL Total Budget 6,000 12,000 0 1,200 1,200 0 11,300 15,000 1,200 0 47,900 Percent to Grant 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Amount to Grant 0 0 0 0 0 0 Amount to Grant 0 0 0 Amount to Grant 0 0 0 0 0 0 0 0 0 0 0 LEGAL, FINANCIAL AND INSURANCE - SUPPORTIVE SERVICES 1 Fidelity Bond (or Equivalent) Directors and Officers General Commercial Liability Contract Accounting Audit Fees Business Auto Insurance TOTAL Short -Term Rent Assistance Short Teen Mortgage Assistance Short Term Utilities Assistance TOTAL Total Budget 500 2,360 3,033 0 11,500 4 039 21,432 Percent to Grant 100% 0% 26.57% 0% 13.04% 0% 13% DIRECT ASSISTANCE - STRMU Total Budget 0 0 0 0 Percent to Grant Amount to Grant 500 0 806 0 1,500 0 2,806 Amount to Grant 0 0 0 0 HOPWA PSA CONTRACT 2015-2016 TalTant County Samaritan House, Inc. EXHIBIT "B" — BUDGET Page 5 Tenant Based Rental Assistance TOTAL DIRECT ASSISTANCE - TBRA Total Budget Percent to Grant 1 Amount to Grant 232,000 0% I 0 232,000 1 0 HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "B" — BUDGET Page 6 Tarrant County Samaritan House, Inc EXHIBIT "C" AUDIT CERTIFICATION FORM HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "C" — AUDIT CERTIFICATION FORM Page 1 Tarrant County Samaritan Housing, Inc. atory an d Title AUDIT CERTIFICATION FORM AND AUDIT REQUIREMENTS Agency: Tarrant County Samaritan Housing, Inc. Fiscal Year Ending: September 30, 2016 During the fiscal year in which funds will be received, we will exceed the federal expenditure threshold of $750,000. We will have our Single Audit or Program Specific Audit completed and will submit the audit report described in 2 CFR Part 200 within 7 months after the end of the audited fiscal year or 30 days within its completion, whichever is the earlier date. n During the fiscal year in which funds will be received, we will not exceed the $750,000 federal expenditure threshold required for a Single Audit or a Program Specific Audit to be performed this fiscal year. (Fill out schedule below) Federal Expenditure Disclosure MUST be filled out if Single Audit or Program Audit is NOT required. Pass Through Program Name & Contract Federal Grantor Grantor CFDA Number Number Expenditures i Failure to submit this or a similar statement or failure to submit a completed single audit package as described in the federally required audit requirements described in 2 CFR Part 200, as applicable, by the required due date may result in suspension of funding and may affect eligibility for future funding. Notwithstanding the above, this certification acknowledges the agency's commitment to meet all other financial reporting, financial statements, and other audit requirements as may be set forth in the Contract. Total Federal Expenditures for this Fiscal Year: HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "C" — AUDIT CERTIFICATION FORM Page 2 Tarrant County Samaritan Housing, Inc. EXHIBIT "D" REPORTING FORMS HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "D" — REPORTING FORMS Page 1 Tarrant County Samaritan Housing, Inc. ATTACHMENT I Invoice - Administration INVOICE HOPWA Administrative Agency: Tarrant County Samaritan House, Inc. Address: City, State Zip* Program. Samaritan House Supportive Services Period of Service: Program Administrative Amount This invoice Cumulative to Date 1 1 Agency's Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false fictitious or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims, or otherwise. U.S. Code Title 18, Sec. 1001 and Title 31, Sec. 3729-3730 and 3801-3812. Signature and Date: Name: Title: HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "D" — REPORTING FORMS Page 2 Tarrant County Samaritan Housing, Inc. ATTACHMENT I Invoice — Supportive Services INVOICE HOPWA Supportive Services Agency: Tarrant County Samaritan House, Inc. Address: City, State Zip* Program. Samaritan House Supportive Services Period of Service: Program Supportive Services Amount This invoice Cumulative to Date Agency's Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false, fictitious or fraudulent information, or the omission of any material fact, may subject me to criminal, civil, or administrative penalties for fraud, false statements, false claims, or otherwise. U.S. Code Title 18, Sec. 1001 and Title 31 Sec. 3729-3730 and 3801-3812. Signature and Date: Name: Title: HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "D" — REPORTING FORMS Page 3 Tarrant County Samaritan Housing, Inc. ATTACHMENT I Invoice — Facility Based Operations INVOICE HOPWA Facility Based Operating Expenses Agency: Tarrant County Samaritan House, Inc. Address: City, State Zip Program. Samaritan House Supportive Services Period of Service: Program Facility Based Operating Expenses Amount This Invoice Cumulative to Date Agency's Certification: By signing this report, I certify to the best of my knowledge and belief that the report is true, complete, and accurate, and the expenditures, disbursements and cash receipts are for the purposes and objectives set forth in the terms and conditions of the Federal award. I am aware that any false fictitious or fraudulent information, or the omission of any material fact, may subject me to criminal civil, or administrative penalties for fraud, false statements, false claims, or otherwise. U.S. Code Title 18, Sec. 1001 and Title 31, Sec. 3729-3730 and 3801-3812. Signature and Date: Name: Title: HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "D" — REPORTING FORMS Page 4 Tart ant County Samai itan Housing, Inc. Line No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Total Agency: Program: ClcckNo. Payee ATTACHMENT II Expenditure Worksheet — Administration HOPWA Administrative City of Fort North Housing and Economic Development Department Expenditure Worksheet Tarrant County Samaritan House, Inc. Samaritan Rouse Supportive Senices Description' Please group like accoun Accourg Code (See Keyto Right) *Payroll must identify employee. Rent must identify tenant. Other payments should identify individuals, if applicable. codes. Amount Highlighted are the only relevant codes for this Program, Expense Line Item ADMINISTRATIVE (HOPWA Only) Salaries FICA Life hrsumnce Health Insurance Disability Insurance Unemployment -State Workers Comp PROGRAMPERSONNEL Salaries FICA Life Insurance Health Insurance Unemployment Worker's Compensation Retirement SUPPLIES AND SERVICES Office Supplies Office Equipment Rental Postage Printing MISCELLANEOUS Construction/Building Materials Contract Labor - Accounting/ IT Craft Supplies Field Trio Admission Expenses Food Supplies Teaching Aids FACUITYAND UTILITIES Telephone Electric Gas Water and Wastewater Solid Waste Disposal Rent Custodial Senices Repairs Cleaning Supplies Building Security LEGAL,F1NANCIAL,AND INSURANCE Fidelity Bond or Equivalent Directors and Officers General Commercial Liability Contract Accounting Audit Fees DIRECTASSISTANCE Childcare Scholarships DIRECT ASSISTANCE - STRMIU Short-term Rent Assistance Short-term Mortgage Assistance Short-term Utilities Assistance DIRECTASSISTANCE- STRMU Tenant Based Rental Assistance FACIIITYBASED OPERATION EXPENSES Salaries FICA Life Insurance Health Insurance Disability Insurance Unemployment -State Worker's Compensation Accounting Retirement Insurance Account 1001 1002 1003 1004 1005 1006 1007 2001 2002 2003 2004 2005 2006 2007 3001 3002 3003 3004 4002 4003 4004 4005 4006 4007 5001 5002 5003 5004 5005 I 5006 5007 5008 5009 5010 6001 6002 6003 6004 6005 7001 7002 7003 7004 7005 8001 8002 8003 8004 8005 8006 8007 8008 8009 8010 HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "D" — REPORTING FORMS Page 5 Tarrant County Samaritan Housing, Inc. Line No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Total Agency: Program: CheckNo.I ATTACHMENT II Expenditure Worksheet — Supportive Services HOPWA Supportive Services City of Fort Worth Housing and Economic Development Department Expenditure Worksheet Tarrant County Samaritan House, Inc. Samaritan House Supportive Services Please group like account codes. Account Code (See Payee Description* Eev to Right) Amount *Payroll must identify employee. Rent must identify tenant. Other payments should identify indisiduals, if applicable. Highlighted are the only relevant codes for this Program. Expense Line Item ADMINISTRATIVE (HOP WA Only) Salaries FICA Life Insurance Health Insurance Disability Insurance Unemployment -State Legal& Accounting PROGRAM PERSONNEL Salaries FICA Life Insurance Health Insurance Unemployment Workers Compensation Retirement SUPPLIES AND SERVICES Office Supplies Office Equipment Renal Postage Printing MISCELLANEOUS Construction/Building Materials Contract Labor - Accounting/ IT Craft Supplies Field Trip Admission Expenses Food Supplies Teaching Aids FACILI7YAND UTILITIES Telephone Electric Gas Water and Wastewater Solid Waste Disposal Rent Custodial Senices Repairs Cleaning Supplies Building Secants' LEGAL, FINANCIAL, AND INSURANCE FidelityBond orEquisaient Directors and Officers General Commercial Liability Contract Accounting Audit Fees DIRECTACSISTANC£ Childcare Scholarships DHtECTAS.SISTANCE- STEM Start -term Rent Assistance Short -teen Mortgage Assistance Short-term Utilities Assistance DHtECTASSISTANCE- STRMU Tenant Based Rental Assistance EACILTIYBASED OPERATION EXPENSES Salaries FICA Life Insurance Health Insurance Disability Insurance Unemployment -Stale Worker's Compensation Accounting Retirement Insurance Account 1001 1002 1003 1004 1005 1006 1007 2001 2002 2003 2004 2005 2006 2007 3001 3002 3003 3004 4002 4003 4004 4005 1 4006 1 4007 5001 5002 5003 5004 5005 5006 5007 5008 5009 5010 6001 6002 6003 6004 6005 7001 7002 7003 7004 7005 8001 8002 8003 8004 8005 8006 1 8007 8008 1 8009 1 8010 HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "D" — REPORTING FORMS Page 6 Tarrant County Samaritan Housing, Inc. Lute No. 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Total Agency: Program: CheckNo. Payee ATTACHMENT II Expenditure Worksheet — Facility Based Operations HOPWA Facility Based Operating Expenses City of Fort Worth Housing and Economic Development Department Expenditure Worksheet Tarrant County Samaritan House, Inc. Samaritan House Supportive Services Description* Please group like account codes. Account Code (See Key to Rigid) Amount +'Payroll must identify employee. Rem must identify tenant. Other payments should identify indisiduals, if applicable. Highlighted are the only relevant codes for this Program. Expense Line Item ADMINISIRAHVE (HOPWA Only) c-tangs FICA Life Insurance Healthlnsurance Disability Insurance Ummployment-State Legal & Accounting PROGRAMPERSONNEL Salaries FICA Life Insurance Health Insurance Unemployment Worker's Compensation Retirement SUPPLIES AND SERVICES Office Supplies Office Equipment Rental Postage Printing MISCELLANEOUS Construction/Building Materials Contract Labor- Accounting/ IT Craft Supplies Field Trip Admission Expenses Food Supplies Teaching Aids FACHITYAND UTILITIES Telephone Electric Electric Gas Water and Wastewater Solid Waste Disposal Rent Custodial Services Repairs Cleaning Supplies Building Security LEGAL. FINANCIAL, AND INSURANCE Fidelity Bond or Equhalent Directors and Officers General Commercial Liability Contract Accounting Audit Fees DIRECTASSISTANCE Childcare Scholarships DIRECTASSISTANCE- STRAW Short-term Rent Assistance Shon-term Mortgage Assistance Short-term Utilities Assistance DHtECTASSISTAN CE - STRMU Tenant Based Rental Assistance FACHITVBASED OPERATION EAPENSES Salaries FICA Life Insurance Health Insurance Disability Insurance Uremploytnent-State Worker's Compensation Accounting Retirement Insurance Account 1001 1002 1003 1004 1005 1006 1007 2001 2002 2003 2004 2005 2006 2007 3001 3002 3003 3004 4002 4003 4004 4005 4006 4007 5001 5002 5003 5004 5005 5006 5007 5008 5009 5010 6001 6002 6003 6004 6005 7001 7002 7003 7004 7005 8001 8002 8003 8004 8005 8006 8007 8008 I 8009 8010 HOPWA PSA CONTRACT 2015-2016 — EXHIBIT "D" — REPORTING FORMS Page 7 Tarrant County Samaritan Housmg, Inc. Instructuns: 1 2 r'. _T r: c•zTH ta £•ll 7.0 2.1 =s\hELCC%TV N 1r£ A7CUCAEL E, 1 2 13 1 5 6 7 IR 19 11 12 1 131 1i 15 16 17 1 18 19 I0 71 22 71 21 1 75 7F 77 8 2) 39 Accney: Pro_tnm: Month: ATTACHMENT III Client Data Report — Supportive Services Tarrant County Samaritan House. Inc. Samaritan House Supporthe Services HO= F WAFTS -Act Srerra Atnirr - av-pit ne Seri:a That•mpg rt1rrani fa11st all =AO =Led dints sena &rim thr tracttern (Ortcker1.2013fa3.2OIt Each cm aria ticaamart tkelakra=laesldIntemlprnlsnal7rtpeafed.%oaren¢irdtoaltcheltealflyovi6ettoc rdsntebrnth arrdlnat ?kw tadF,tlratrlcilexr shcddtells'rdt<I:react.jredya!lripenedsastothattlisderfsillrtsaantllrtdlr. Firm' thy11aill rats ere d e°thefrrla:abthttheireainIenlce. al earCstadlmetatredvePrevarayentasfraidjlencadscdltardlsbelldrdeardear. 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AFLIC `: 9 erth 'Ye) TES I I 1 I I 1 I 10 It 1E11 eTAt (c tI cIree 1 e (te 5 cdna) O?e Asa 11111 w bat ti-S3 lSl r t•IN1-3 Yctn AN1 tr671.3 K1 r SUE saa Y+J 1 !1-K% .04 Listrtos aatsaa r. all [Awns) 1 Vial nn tss••;...: 1-111 r truss! 1 Cs= try. l fc+ I AL 1 11:1S I f I I +I 1 i 12 Cry) 1ES HOPWA PSA CONTRACT 2015-2016 Tarrant County Samaritan Housing, Inc. EXHIBIT "D" REPORTING FORMS Page 8 EXHIBIT "E" INCOME CERTIFICATION FORMS HOPWA CONTRACT 2015-2016 -- EXHIBIT "E" -- INCOME CERTIFICATION FORMS Page 1 Tarrant County Samaritan Housing, Inc. Tarrant County Samaritan Housing, Inc. CERTIFICATION OF INCOME STATEMENT Applicant Name: Current Address: Phone : Last Name First Name Household Members and Income (Including Applicant) Age Monthly Source/Employer Name Income **PERSONAL INFORMATION: (Check one in each item. Optional Information for Federal Reporting Purposes) a. ■ MALE b. ❑ WHITE ❑ BLACK/AFRICAN AMERICAN 0 BLACK/AFRICAN AMERICAN & WHITE ❑ FEMALE ■ AMERICAN INDIAN/ALASKAN NATIVE ■ ASIAN 0 AMERICAN INDIAN/ALASKAN NATIVE & WHITE ❑ ASIAN & WHITE NATIVE HAWAIIAN/OTHER PACIFIC ISLANDER 0 BALANCE/OTHER AMERICAN INDIAN/ALASKAN NATIVE & BLACK/AFRICAN AMERICAN ■ c. ETHNICITY d. DISABLED e. IS CLIENT WOMEN HEAD OF HOUSEHOLD ❑ HISPANIC ❑ YES 0 YES ❑ NON -HISPANIC ■ NO 0 NO * TOTAL NUMBER OF HOUSEHOLD MEMBERS Total Anticipated Annual Household Income• (Include Yourself AND everyone who lives in the house.) Certification: I certify that the information I am providing is true and could be subject to verification at any time by a third party. I also acknowledge that the provision of false information could leave me subject to the penalties of Federal, State and local law. WARNING: TITLE 18, SECTION 1001 OF THE U.S. CODE STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OF THE UNITED STATES GOVERNMENT. Signature of Applicant Date For use by Agency staff only Household Size: Gross Annual Income• Applicable Income Limit: Is Applicant Eligible? Check if Applicant refused to provide demographic information E Staff Assessment of Demographics Person Making Determination: Date: NOTE: Address, income amounts and sources for ALL household members are required. HOPWA CONTRACT 2015-2016 -- EXHIBIT "E" -- INCOME CERTIFICATION FORMS Page 2 Tarrant County Samaritan Housing, Inc. Tarrant County Samaritan Housing, Inc. CERTIFICACION DE DECLARACION DE INGRESOS Nombre del Solicitante: Domicilio Actual: Numero de Telefono Miembros en el Hogar e Inaresos (Incluir el/la solicitante) Apellido Nombre Edad Ingreso Fuente de Ingresos/Nombre de Empleador Mensual **INFORMACION PERSONAL: (Seleccione uno en cada categoria. Informacion opcional para proposrtos de informacion Federal) a. ■ MASCULINO b. 0 CAUCASICO ❑ NEGRO/AFRICANO AMERICANO ❑ NEGRO/AFRICANO AMERICANO & CAUCASICO ❑ FEMININO ❑ INDIO AMERICANO/NATIVO DE ALASKA 0 ASIATICO ❑ INDIO AMERICANO/NATIVO DE ALASKA & CAUCASICO ■ ASIATICO & CAUCASICO ❑ NATIVO HAWAIANO/OTRO DE LAS ISLAS PACIFICAS ❑ BALANCE/OTRO n INDIO AMERICANO / NATIVO DE ALASKA & NEGRO/AFRICANO AMERICANO c. ETNICIDAD d. DISCAPACITADO e. 1,ES EL SOLICITANTE UNA MUJER Y CABECERA DEL HOGAR? ❑ HISPANO ❑ SI ❑ SI ❑ NO-HISPANO n NO n NO * NUMERO TOTAL DE MIEMBROS EN EL HOGAR Ingreso total del hogar anual anticipado: (Incluye a si mismo y a todos los que viven en la casa) Certificacion• Certifico que la informacion que proporciono es verdad y podria ser susceptible a la comprobacion a cualquier tiempo por terceros. Yo tambien reconozco que la provision de infoiniacion falsa me podria dejar sujeto a las penalidades Federales, Estatales y locales. ADVERTENCIA: TITULO 18, SECCION 1001 DEL CODIGO DE EE.UU. QUE UNA PERSONA Es CULPABLE DE UN DELITO POR SABER Y VOLUNTARIAMENTE HACER DECLARACIONES FALSAS 0 FRAUDULENTAS A CUALQUIER DEPARTAMENTO DEL GOBIERNO ESTADOUNIDENSE. Firma del Solicitante Fecha Para use de etnpleados de la agencia # De Miembros de Familia: Ingreso Anual: Limite de Ingreso: 1,Es solicitante elegible? : Compruebe si el solicitante se nego a dar su informacion personal* C Fvaluacion del empleado sobre infointacion personal: Persona haciendo la detelnninacion: Fecha: Note: La direccion de la casa y los ingresos (y sus origenes) para todos miembros del hogar son requeridos. HOPWA CONTRACT 2015-2016 -- EXHIBIT "E" -- INCOME CERTIFICATION FORMS Page 3 Tarrant County Samaritan Housing, Inc. EXHIBIT "F" STANDARDS OF DOCUMENTATION HOPWA PSA CONTRACT 2015-2016 -- EXHIBIT "F" -- STANDARDS OF DOCUMENTATION Page 1 Tarrant County Samaritan Housing, Inc. 2015-2016 Documentation Standards for HOPWA Public Service Contract Expenses Employee Salaries and Benefits - City will reimburse the salary and benefits of any employee(s) who work directly with the HOPWA Program. Amounts will be determined prior to the execution of the HOPWA Contract. Agencies must show calculation on how the HOPWA portion of employee salaries and benefits were calculated consistently with the HOPWA Contract. The calculation(s) will apply to the HOPWA Administration line item, Supportive Services, and Facility Based Operations. neIIIIuta buil lei it req Ueblb IIIUbL IIll.luue d LIIIIeblleel allu WUIt\ iuy ll tat leuleLaW the IIVUIJ WUII\cu uy Ll le CIIIpiuyce\Jf WUItduit-{ u11Cutiy VII Lllc HOPWA-funded Program. For employees who are paid with multiple funding sources, timesheets must reflect all funding sources. If separate timesheets are kept for each funding source, all such timesheets must be submitted to City. Timesheets must be signed by employee and supervisor. Agency must show a calculation and documentation of how the employee's salary was calculated and invoiced to City. For employees who are paid with multiple funding sources, timesheets must reflect all funding sources. If separate timesheets are kept for each funding source, all such timesheets must be submitted to City. The duties for administrative personnel defined by the job descriptions must reflect eligible administrative costs. Agencies will be required to identify hours worked on a specific activity, i.e. Administrative, Supportive, or Operations. Salaries FICA/ Medicare Life Insurance Health Insurance Disability Insurance Unemployment Insurance Administrative Services: Employees who work hours for the general management, oversight, coordination, evaluation, and reporting of HOPWA-eligible activities will be required to supply documentation reflecting hours worked on the HOPWA-funded Program. The duties for administrative personnel defined by the job descriptions must reflect eligible administrative costs. Supportive Services: Employees who work hours for direct client support, which includes but is not limited to housing case managment to clients, assessing and monitor the client's needs and personal support systems, assisting clients with housing assesments, housing plans, filling out intake forms, coordinating payment with hotels/motels, and provides referrals to other housing sources, etc. will be required to supply documentation reflecting hours worked directly with clients. Facility Based Operations: Employees who work hours for the daily and ongoing operation of a facility or facilities will be required to supply documentation reflecting hours worked on the operation of a facility or facilities. *If employees are paid by direct deposit rather than check, then the agency must submit both the direct deposit payment company's report If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and must provide documentation showing payment. If the City pays gross salary, this is already included. If the City pays the employer portion, the Agency must provide proof that the employee is enrolled in the benefit plan, must show a calculation and documentation of how the invoiced amount was calculated, and must provide documentation showing payment. Materials, Equipment, Goods and Supplies - City will only reimburse for the amount spent on the direct support of the HOPWA-funded Program. Agencies requesting reimbursement for these items will require prior City approval. Agencies must show calculation on how the HOPWA portion of these expenses were calculated consistently with the HOPWA Contract. Costs must be reasonable and documented expenses. X X X X X X X X X X Retirement X X Office Supplies X Office Equipment Rental Postage Printing/Copies Medical Supplies Rent, Utilities and Maintenance - City will only pay for a prorated portion of these expenses. The portion will be determined by the square footage attributable to the HOPWA, funded Program and shall be cost -allocated in accordance with the amount of space used for the HOPWA-funded Program. These expenses may only be in support of the HOPWA-funded Program. The items listed below require prior City approval and the Agency is required to identify any funding source that pays for the portion of the expenses that is not paid with City HOPWA funds. Agencies must show calculation on how the HOPWA portion of these expenses were calculated consistently with the HOPWA Contract. Telephone Gas Water/ Wastewater Electric Solid Waste Disposal Facility Maintenance and Repairs X X X X Rent X X X XIXI I I x X X X I X X X X X X X X X X X X X X X X These costs can be associated with the delivery of a HOPWA activity provided by the Agency. Agencies will be required to identify which expenses will be allocated to specific activities, i.e. Administrative, Supportive, or Operations. This item requires approval by the City prior to the execution of the HOPWA Contract. Repairs may be categorized as major/minor rehabilitation projects and must be approved through the full HUD Environmetal Review. City will pay for a portion of the rent for the Program facility so long as its in proportion to the square footage attributable to the HOPWA- funded program. HOPWA PSA CONTRACT 2015-2016 Exhibit "F" -- STANDARDS FOR COMPLETE DOCUMENTATION Supportive Services, STRMU/TBRA Client Eligibility Documentation Demograhic Information Medical Documentation STRMU Client X X TBRA Client Miscellaneous City -required Insurance Other Insurance X X X X X X Procurement - X X X X Contract Labor Audit Services X X X HOPWA CAPER Quarterly Report X X X Client documentation provided must reflect demographic & household/family composition. Agency will submit information in the form of a letter that certifies that the Agency has medical documentation confirming the clients' HIV/AIDS status. Agency will submit documentation that demonstrate compliance with the assistance time limits, 21 weeks in any 52 week period, complete lease, utility bill(s), proof of emergency situation, and income source documentation to show clients is at or below 80% AMI. Agency will submit documentation that demonstrates the client was certified on an annual basis through an annual income certification or recertification, submit a complete lease, utility bill(s), Habitability Inspection or Housing Quality Standard (HQS) Inspection, Rent Reasonableness, and income source documentation to show client is at or below 80% AMI. City will only pay for a percentage of the City -required insurance solong as it is in proportion to the square footage attributable to the HOPWA-funded program. City will only pay for a percentage of other required insurance. Insurance such as, but not limited to, Commercial Property and Liability, Professional Liability, Crime and Fidelity, Business Auto, and Commercial Umbrella Liability, solong as it is in proportion to Agencies total budget. Agencies will be required to identify which expenses will be allocated to specific activities, i.e. Administrative, Supportive, or Operations. Agency must show a calculation and documentation of how the invoiced amount was calculated, and must provide documentation showing payment. This item requires prior approval by the City. Prior to the execution of the ESG Contract, the Agency must submit a written statement that lists the contract labor services to be used during the Contract term. Agency will submit a memo related to the procurement of such X services and will forward any information pertaining to the procurement process to City. This requirement applies to, but is not limited to, services retained for security services, legal, accounting, transportation providers, educational facilitators, nutritionist, hazmat services, custodial services, etc. Agencies may not use the contract services of any City of Fort Worth Department. If an audit is required because federal funds exceed $750,000, then the cost should be split evenly by all grant funding sources. Agency must show calculation on how the CDBG portion of the accounting services were calculated. For example, if the CDBG grant is 10% of your Agency's budget, then invoice shall not exceed 10% of the overall cost. Agency must show a calculation and documentation of how the invoiced amount was calculated, and must provide documentation showing payment. Agency must submit a HOPWA CAPER quarterly report. *Proof of payment effective October 1, 2013: Payments or Expenses must be documented in the following manner: A) Image of the check AND bank statement showing the check cleared the bank; OR, B) Image of the cancelled check (ex. At end of bank statement); OR, C) Payroll Check Stub, "Advice", or Statement AND Bank Statement indicating payroll; OR, D) For wire or e-transfers: Reciept or statement from payee/vendor OR bank statement. Final as of 08 28 2015 thr HOPWA PSA CONTRACT 2015-2016 Exhibit "F" -- STANDARDS FOR COMPLETE DOCUMENTATION 1 EXHIBIT "G" SECTION 3 REPORTING FORMS HOPWA PSA CONTRACT 2015-2016 -- EXHIBIT "G" -- SECTION 3 REPORTING FORMS Page 1 Tarrant County Samaritan Housmg, Inc. EXHIBIT "G" Section 3 Summary Report Economic Opportunities for Low — and Very Low -Income Persons Section back of page for Public Reporting Burden statement U.S. Department of Housing and Urban Development Office of Fair Housing And Equal Opportunity 1. Recipient Name & Address: (street, city, state, zip) 2. Federal Identification: (grant no.) 4. Contact Person 6 Length of Grant: 8. Date Report Submitted: 9. Program Code: (Use separate sheet for each program code) Part I: Employment and Training (** Columns B, C and F are mandatory fields. Include New A B Number of Job Category New Hires Professionals Technicians Office/Clerical Construction by Trade (List) Trade Trade Trade Trade Trade Other (List) Total * Program Codes 1 = Flexible Subsidy 2 = Section 202/811 c Number of New Hires that are Sec. 3 Residents 3 = Public/lndian Housing A = Development, B = Operation C = Modernization D of Aggregate Number of Staff Hours of New Hires that are Sec. 3 Residents OMB Approval No: 2529-0043 (exp. 11/30/2010) HUD Field Office: 3. Total Amount of Award: 5. Phone: (Include area code) 7. Reporting Period: 10. Program Name: Hires in E &F) E of Total Staff Hours for Section 3 Employees and Trainees 4 = Homeless Assistance 5=HOME 6 = HOME State Administered 7 = CDBG Entitlement F Number of Section 3 Trainees 8 = CDBG State Administered 9 = Other CD Programs 10 = Other Housing Programs Page 1 of 2 form HUD 60002 (6/2001) Ref 24 CFR 135 Part 11: Contracts Awarded 1. Construction Contracts: A. Total dollar amount of all contracts awarded on the project B. Total dollar amount of contracts awarded to Section 3 businesses C. Percentage of the total dollar amount that was awarded to Section 3 businesses D. Total number of Section 3 businesses receiving contracts 2. Non -Construction Contracts: A. Total dollar amount all non -construction contracts awarded on the project/activity $ B. Total dollar amount of non -construction contracts awarded to Section 3 businesses $ C. Percentage of the total dollar amount that was awarded to Section 3 businesses D. Total number of Section 3 businesses receiving non -construction contracts Part III: Summary Indicate the efforts made to direct the employment and other economic opportunities generated by HUD financial assistance for housing and community development programs, to the greatest extent feasible, toward low -and very low-income persons particularly those who are recipients of government assistance for housing. (Check all that apply.) Attempted to recruit low-income residents through: local advertising media, signs prominently displayed at the project site, contracts with the community organizations and public or private agencies operating within the metropolitan area (or nonmetropolitan county) in which the Section 3 covered program or project is located, or similar methods. Participated in a HUD program or other program which promotes the training or employment of Section 3 residents. Participated in a HUD program or other program which promotes the award of contracts to business concerns which meet the definition of Section 3 business concerns. Coordinated with Youthbuild Programs administered in the metropolitan area in which the Section 3 covered project is located. Other describe below. Public reporting for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. This agency may not collect this information, and you are not required to complete this form, unless it displays a currently valid OMB number. Section 3 of the Housing and Urban Development Act of 1968, as amended, 12 U.S.C. 1701 u, mandates that the Department ensures that employment and other economic opportunities generated by its housing and community development assistance programs are directed toward low- and very -low income persons, particularly those who are recipients of government assistance housing. The regulations are found at 24 CFR Part 135. The information will be used by the Department to monitor program recipients' compliance with Section 3, to assess the results of the Department's efforts to meet the statutory objectives of Section 3 to prepare reports to Congress, and by recipients as self -monitoring tool. The data is entered into a database and will be analyzed and distributed. The collection of information involves recipients receiving Federal financial assistance for housing and community development programs covered by Section 3. The information will be collected annually to assist HUD in meeting its reporting requirements under Section 808(e)(6) of the Fair Housing Act and Section 916 of the HCDA of 1992 An assurance of confidentiality is not applicable to this form. The Privacy Act of 1974 and OMB Circular A-108 are not applicable. The reporting requirements do not contain sensitive questions. Data is cumulative; personal identifying information is not included. Page 2 of 2 form HUD 60002 (11/2010) Ref 24 CFR 135 Form HUD-60002, Section 3 Summary Report, Economic Opportunities for Low- and Very Low -Income Persons. Instructions: This form is to be used to report annual accomplishments regarding employment and other economic opportunities provided to low- and very low-income persons under Section 3 of the Housing and Urban Development Act of 1968. The Section 3 regulations apply to any public and Indian housing programs that receive: (1) development assistance pursuant to Section 5 of the U.S. Housing Act of 1937; (2) operating assistance pursuant to Section 9 of the U.S. Housing Act of 1937; or (3) modernization grants pursuant to Section 14 of the U.S. Housing Act of 1937 and to recipients of housing and community development assistance in excess of $200,000 expended for (1) housing rehabilitation (including reduction and abatement of lead -based paint hazards); (2) housing construction; or (3) other public construction projects; and to contracts and subcontracts in excess of $100,000 awarded in connection with the Section-3-covered activity. Form HUD-60002 has three parts, which are to be completed for all programs covered by Section 3. Part I relates to employment and training. The recipient has the option to determine numerical employment/training goals either on the basis of the number of hours worked by new hires (columns B, D, E and F). Part II of the form relates to contracting, and Part III summarizes recipients' efforts to comply with Section 3. Recipients or contractors subject to Section 3 requirements must maintain appropriate documentation to establish that HUD financial assistance for housing and community development programs were directed toward low- and very low-income persons.* A recipient of Section 3 covered assistance shall submit one copy of this report to HUD Headquarters, Office of Fair Housing and Equal Opportunity. Where the program providing assistance requires an annual performance report, this Section 3 report is to be submitted at the same time the program performance report is submitted. Where an annual performance report is not required, this Section 3 report is to be submitted by January 10 and, if the project ends before December 31, within 10 days of project completion. Only Prime Recipients are required to report to HUD. The report must include accomplishments of all recipients and their Section 3 covered contractors and subcontractors. HUD Field Office: Enter the Field Office name 1. Recipient: Enter the name and address of the recipient submitting this report. 2. Federal Identification: Enter the number that appears on the award form (with dashes). The award may be a grant, cooperative agreement or contract. 3. Dollar Amount of Award: Enter the dollar amount, rounded to the nearest dollar, received by the recipient. 4 & 5. Contact Person/Phone: Enter the name and telephone number of the person with knowledge of the award and the recipient's implementation of Section 3. 6. Reporting Period: Indicate the time period (months and year) this report covers. 7. Date Report Submitted: Enter the appropriate date. Submit one (1) copy of this report to the HUD Headquarters Office of Fair Housing and Equal Opportunity, at the same time the performance report is submitted to the program office. The Section 3 report is submitted by January 10. Include only contracts executed during the period specified in item 8. PHAs/IHAs are to report all contracts/subcontracts. * The terms "low-income persons" and very low-income persons" have the same meanings given the terms in section 3 (b) (2) of the United States Housing Act of 1937. Low-income persons mean families (including single persons) whose incomes do not exceed 80 percent of the median income for the area, as determined by the Secretary, with adjustments for smaller and larger families, except that Page i 8. Program Code: Enter the appropriate program code as listed at the bottom of the page. 9. Program Name: Enter the name of HUD Program corresponding with the "Program Code" in number 8. Part I: Employment and Training Opportunities Column A: Contains various job categories. Professionals are defined as people who have special knowledge of an occupation (i.e. supervisors, architects, surveyors, planners, and computer programmers). For construction positions, list each trade and provide data in columns B through F for each trade where persons were employed. The category of "Other" includes occupations such as service workers. Column B: (Mandatory Field) Enter the number of new hires for each category of workers identified in Column A in connection with this award. New hire refers to a person who is not on the contractor's or recipient's payroll for employment at the time of selection for the Section 3 covered award or at the time of receipt of Section 3 covered assistance. Column C: (Mandatory Field) Enter the number of Section 3 new hires for each category of workers identified in Column A in connection with this award. Section 3 new hire refers to a Section 3 resident who is not on the contractor's or recipient's payroll for employment at the time of selection for the Section 3 covered award or at the time of receipt of Section 3 covered assistance. Column D: Enter the percentage of all the staff hours of new hires (Section 3 residents) in connection with this award. Column E: Enter the percentage of the total staff hours worked for Section 3 employees and trainees (including new hires) connected with this award. Include staff hours for part-time and full-time positions. Column F: (Mandatory Field) Enter the number of Section 3 residents that were trained in connection with this award. Part II: Contract Opportunities Block 1: Construction Contracts Item A: Enter the total dollar amount of all contracts awarded on the project/program. Item B: Enter the total dollar amount of contracts connected with this project/program that were awarded to Section 3 businesses. Item C: Enter the percentage of the total dollar amount of contracts connected with this project/program awarded to Section 3 businesses. Item D: Enter the number of Section 3 businesses receiving awards. Block 2: Non -Construction Contracts Item A: Enter the total dollar amount of all contracts awarded on the project/program. Item B: Enter the total dollar amount of contracts connected with this project awarded to Section 3 businesses. Item C: Enter the percentage of the total dollar amount of contracts connected with this project/program awarded to Section 3 businesses. Item D: Enter the number of Section 3 businesses receiving awards. Part III: Summary of Efforts — Self -explanatory The Secretary may establish income ceilings higher or lower than 80 percent of the median for the area on the basis of the Secretary's findings such that variations are necessary because of prevailing levels of construction costs or unusually high- or low-income families. Very low-income persons mean low-income families (including single persons) whose incomes do not exceed 50 percent of the median family income area, as determined by the Secretary with adjustments or smaller and larger families, except that the Secretary may establish income ceilings higher or lower than 50 percent of the median for the area on the basis of the Secretary's findings that such variations are necessary because of unusually high or low family incomes. form HUD 60002 (11/2010) Ref 24 CFR 135 EXHIBIT "H" OVERVIEW REPORT HOPWA PSA CONTRACT 2015-2016 —EXHIBIT "H" — OVERVIEW REPORT Page 1 Tarrant County Samaritan Housmg, Inc. Housing Opportunities for Persons with AIDS (HOPWA) Program Consolidated Annual Performance and Evaluation Report ( n' ' ) Measuring Performance Outcomes Final Released 1/12/12 OMB Number 2506-0133 (Expiration Date: 10/31/2014) The CAPER report for HOPWA formula grantees provides annual information on program accomplishments that supports program evaluation and the ability to measure program beneficiary outcomes as related to: maintain housing stability prevent homelessness; and improve access to care and support. This information is also covered under the Consolidated Plan Management Process (CPMP) report and includes Narrative Responses and Performance Charts required under the Consolidated Planning regulations The public reporting burden for the collection of information is estimated to average 42 hours per manual response, or less if an automated data collection and retrieval system is in use, along with 60 hours for record keeping including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information Grantees are required to report on the activities undertaken only, thus there may be components of these reporting requirements that may not be applicable. This agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless that collection displays a valid OMB control number. Previous editions are obsolete form HUD-40110-D (Expiration Date: 10/31/2014) Overview. The Consolidated Annual Performance and Evaluation Report (CAPER) provides annual performance reporting on client outputs and outcomes that enables an assessment of grantee performance in achieving the housing stability outcome measure. The CAPER, in conjunction with the Integrated Disbursement Information System (IDIS), fulfills statutory and regulatory program reporting requirements and provides the grantee and HUD with the necessary information to assess the overall program performance and accomplishments against planned goals and objectives. HOPWA formula grantees are required to submit a CAPER, and complete annual performance information for all activities undertaken during each program year in the IDIS, demonstrating coordination with other Consolidated Plan resources. HUD uses the CAPER and IDIS data to obtain essential information on grant activities, project sponsors, Subrecipient organizations, housing sites, units and households, and beneficiaries (which includes racial and ethnic data on program participants). The Consolidated Plan Management Process tool (CPMP) provides an optional tool to integrate the reporting of HOPWA specific activities with other planning and reporting on Consolidated Plan activities. Table of Contents PART 1: Grantee Executive Summary 1. Grantee Information 2. Project Sponsor Information 3. Administrative Subrecipient Information 4. Program Subrecipient Information 5. Grantee Narrative and Performance Assessment a. Grantee and Community Overview b. Annual Performance under the Action Plan c. Barriers or Trends Overview d. Assessment of Unmet Housing Needs PART 2: Sources of Leveraeine and Proeram Income 1. Sources of Leveraging 2. Program Income and Resident Rent Payments PART 3: Accomnlishment Data: Planned Goals and Actual Outnuts PART 4: Summary of Performance Outcomes 1. Housing Stability. Permanent Housing and Related Facilities 2. Prevention of Homelessness: Short -Term Housing Payments 3. Access to Care and Support: Housing Subsidy Assistance with Supportive Services PART 5: Worksheet - Determining Housing Stability Outcomes PART 6: Annual Certification of Continued Use for HOPWA Facility - Based Stewardshin Units (Only) PART 7: Summary Overview of Grant Activities A. Information on Individuals, Beneficiaries and Households Receiving HOPWA Housing Subsidy Assistance (TBRA, STRMU, PHP,Facility Based Units, Master Leased Units ONLY) B. Facility -Based Housing Assistance Continued Use Periods. Grantees that received HOPWA funding for new construction, acquisition, or substantial rehabilitations are required to operate their facilities for HOPWA-eligible beneficiaries for a ten (10) years period. If no further HOPWA funds are used to support the facility, in place of completing Section 7B of the CAPER, the grantee must submit an Annual Certification of Continued Project Operation throughout the required use periods. This certification is included in Part 6 in CAPER. The required use period is three (3) years if the rehabilitation is non -substantial. In connection with the development of the Department's standards for Homeless Management Information Systems (HMIS), universal data elements are being collected for clients of HOPWA-funded homeless assistance nroiects. These project sponsor/subrecipient records would include: Name, Social Security Number, Date of Birth, Ethnicity and Race, Gender, Veteran Status, Disabling Conditions, Residence Prior to Program Entry, Zip Code of Last Permanent Address, Housing Status Program Entry Date, Program Exit Date, Personal Identification Number, and Household Identification Number. These are intended to match the elements under HMIS. The HOPWA program -level data elements include: Income and Sources, Non -Cash Benefits, HIV/AIDS Status, Services Provided, and Housing Status or Destination at the end of the operating year. Other suggested but optional elements are: Physical Disability, Developmental Disability, Chronic Health Condition, Mental Health, Substance Abuse, Domestic Violence, Date of Contact, Date of Engagement, Financial Assistance, Housing Relocation & Stabilization Services, Employment, Education, General Health Status, , Pregnancy Status Reasons for Leaving, Veteran's Information, and Children's Education. Other HOPWA projects sponsors may also benefit from collecting these data elements. Final Assembly of Report. After the entire report is assembled, please number each page sequentially. Filing Requirements. Within 90 days of the completion of each program year, grantees must submit their completed CAPER to the CPD Director in the grantee's State or Local HUD Field Office, and to the HOPWA Program Office. at HOPWA@hud.aov. Electronic submission to HOPWA Program office is preferred; however, if electronic submission is not possible, hard copies can be mailed to: Office of HIV/AIDS Housing, Room 7212, U.S. Department of Housing and Urban Development, 451 Seventh Street, SW, Washington, D.C. Record Keeping. Names and other individual information must be kept confidential, as required by 24 CFR 574.440. However, HUD reserves the right to review the information used to complete this report for grants management oversight purposes, except for recording any names and other identifying information In the case that HUD must review client level data, no client names or identifying information will be retained or recorded. Information is reported in aggregate to HUD without personal identification. Do not submit client or personal information in data systems to HUD. Definitions Adjustment for Duplication: Enables the calculation of unduplicated output totals by accounting for the total number of households or units that received more than one type of HOPWA assistance in a given service category such as HOPWA Subsidy Assistance or Supportive Services. For example, if a client household received both TBRA and STRMU during the operating year, report that household in the category of HOPWA Housing Subsidy Assistance in Part 3, Chart 1, Column [lb] in the following manner: HOPWA Housing Subsidy Assistance Tenant -Based Rental Assistance Permanent Housing Facilities: 2a. Received Operating Subsidies/Leased units 2b. 3a. 3b. 4. 5. Transitional/Short-term Facilities: Received Operating Subsidies Permanent Housing Facilities: Capital Development Projects placed in service during the operating year Transitional/Short-term Facilities: Capital Development Projects placed in service during the operating year Short-term Rent, Mortgage, and Utility Assistance Adjustment for duplication (subtract) TOTAL Housing Subsidy Assistance (Sum of Rows 1-4 minus Row 5) [1] Outputs: Number of Households 1 Previous editions are obsolete Page i form HUD-40110-D (Expiration Date: 10/31/2014) Administrative Costs: Costs for general management, oversight, coordination, evaluation, and reporting. By statute, grantee administrative costs are limited to 3% of total grant award, to be expended over the life of the grant. Project sponsor administrative costs are limited to 7% of the portion of the grant amount they receive. Beneficiary(ies): All members of a household who received HOPWA assistance during the operating year including the one individual who qualified the household for HOPWA assistance as well as any other members of the household (with or without HIV) who benefitted from the assistance. Central Contractor Registration (CCR): The primary registrant database for the U.S. Federal Government. CCR collects, validates, stores, and disseminates data in support of agency acquisition missions, including Federal agency contract and assistance awards. Both current and potential federal government registrants (grantees) are required to register in CCR in order to be awarded contracts by the federal government. Registrants must update or renew their registration at least once per year to maintain an active status. Although recipients of direct federal contracts and grant awards have been required to be registered with CCR since 2003, this requirement is now being extended to indirect recipients of federal funds with the passage of ARRA (American Recovery and Reinvestment Act). Per ARRA and FFATA (Federal Funding Accountability and Transparency Act) federal regulations, all grantees and sub -grantees or subcontractors receiving federal grant awards or contracts must have a DUNS (Data Universal Numbering System) Number. Chronically Homeless Person: An individual or family who : (i) is homeless and lives or resides individual or family who: (i) Is homeless and lives or resides in a place not meant for human habitation, a safe haven, or in an emergency shelter; (ii) has been homeless and living or residing in a place not meant for human habitation, a safe haven, or in an emergency shelter continuously for at least 1 year or on at least 4 separate occasions in the last 3 years; and (iii) has an adult head of household (or a minor head of household if no adult is present in the household) with a diagnosable substance use disorder, serious mental illness, developmental disability (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.0 15002)), post traumatic stress disorder, cognitive impairments resulting from a brain injury, or chronic physical illness or disability, including the co -occurrence of 2 or more of those conditions. Additionally, the statutory definition includes as chronically homeless a person who currently lives or resides in an institutional care facility, including a jail, substance abuse or mental health treatment facility, hospital or other similar facility, and has resided there for fewer than 90 days if such person met the other criteria for homeless prior to entering that facility. (See 42 U.S.C. 11360(2))This does not include doubled -up or overcrowding situations. Disabling Condition: Evidencing a diagnosable substance use disorder, serious mental illness, developmental disability, chronic physical illness, or disability, including the co -occurrence of two or more of these conditions. In addition, a disabling condition may limit an individual's ability to work or perform one or more activities of daily living. An HIV/AIDS diagnosis is considered a disabling condition. Facility -Based Housing Assistance: All eligible HOPWA Housing expenditures for or associated with supporting facilities including community residences, SRO dwellings, short-term facilities, project -based rental units, master leased units, and other housing facilities approved by HUD. Faith -Based Organization: Religious organizations of three types: (1) congregations; (2) national networks, which include national denominations, their social service arms (for example, Catholic Charities, Lutheran Social Services), and networks of related organizations (such as YMCA and YWCA); and (3) freestanding religious organizations, which are incorporated separately from congregations and national networks. Grassroots Organization* An organization headquartered in the local community where it provides services; has a social services budget of $300,000 or less annually, and six or fewer full-time equivalent employees. Local affiliates of national organizations are not considered "grassroots." HOPWA Eligible Individual: The one (1) low-income person with HIV/AIDS who qualifies a household for HOPWA assistance. This person may be considered ` Head of Household." When the CAPER asks for information on eligible individuals, report on this individual person only. Where there is more than one person with HIV/AIDS in the household, the additional PWH/A(s), would be considered a beneficiary(s). HOPWA Housing Information Services: Services dedicated to helping persons living with HIV/AIDS and their families to identify, locate, and acquire housing. This may also include fair housing counseling for eligible persons who may encounter discrimination based on race, color, religion, sex, age, national origin, familial status, or handicap/disability. . HOPWA Housing Subsidy Assistance Total: The unduplicated number of households receiving housing subsidies (TBRA, STRMU, Permanent Housing Placement services and Master Leasing) and/or residing in units of facilities dedicated to persons living with HIV/AIDS and their families and supported with HOPWA funds during the operating year Household: A single individual or a family composed of two or more persons for which household incomes are used to determine eligibility and for calculation of the resident rent payment. The term is used for collecting data on changes in income, changes in access to services, receipt of housing information services, and outcomes on achieving housing stability. Live -In Aides (see definition for Live -In Aide) and non - beneficiaries (e.g. a shared housing arrangement with a roommate) who resided in the unit are not reported on in the CAPER. Housing Stability: The degree to which the HOPWA project assisted beneficiaries to remain in stable housing during the operating year. See Part 5: Determining Housing Stability Outcomes for definitions of stable and unstable housing situations. In -kind Leveraged Resources: These involve additional types of support provided to assist HOPWA beneficiaries such as volunteer services, materials, use of equipment and building space. The actual value of the support can be the contribution of professional services, based on customary rates for this specialized support, or actual costs contributed from other leveraged resources In determining a rate for the contribution of volunteer time and services, use the rate established in HUD notices, such as the rate of ten dollars per hour. The value of any donated material, equipment, building, or lease should be based on the fair market value at time of donation. Related documentation can be from recent bills of sales, advertised prices, appraisals, or other information for comparable property similarly situated. Leveraged Funds: The amount of funds expended during the operating year from non-HOPWA federal, state, local, and private sources by grantees or sponsors in dedicating assistance to this client population. Leveraged funds or other assistance are used directly in or in support of HOPWA program delivery. Live -In Aide: A person who resides with the HOPWA Eligible Individual and who meets the following criteria: (1) is essential to the care and well- being of the person; (2) is not obligated for the support of the person; and (3) would not be living in the unit except to provide the necessary supportive services. See the Code of Federal Regulations Title 24, Part 5.403 and the HOPWA Grantee Oversight Resource Guide for additional reference. Master Leasing: Applies to a nonprofit or public agency that leases units of housing (scattered -sites or entire buildings) from a landlord, and subleases the units to homeless or low-income tenants. By assuming the tenancy burden, the agency facilitates housing of clients who may not be able to maintain a lease on their own due to poor credit, evictions, or lack of sufficient income. Previous editions are obsolete Page ii form HUD-40110-D (Expiration Date: 10/31/2014) Operating Costs: Applies to facility -based housing only, for facilities that are currently open. Operating costs can include day-to-day housing function and operation costs like utilities, maintenance, equipment insurance, security, furnishings, supplies and salary for staff costs directly related to the housing project but not staff costs for delivering services. Outcome* The degree to which the HOPWA assisted household has been enabled to establish or maintain a stable living environment in housing that is safe, decent, and sanitary, (per the regulations at 24 CFR 574.310(b)) and to reduce the risks of homelessness, and improve access to HIV treatment and other health care and support. Output: The number of units of housing or households that receive HOPWA assistance during the operating year. Permanent Housing Placement: A supportive housing service that helps establish the household in the housing unit, including but not limited to reasonable costs for security deposits not to exceed two months of rent costs. Program Income: Gross income directly generated from the use of HOPWA funds, including repayments. See grant administration requirements on program income for state and local governments at 24 CFR 85.25, or for non -profits at 24 CFR 84.24. Project -Based Rental Assistance (PBRA): A rental subsidy program that is tied to specific facilities or units owned or controlled by a project sponsor or Subrecipient. Assistance is tied directly to the properties and is not portable or transferable. Project Sponsor Organizations: Any nonprofit organization or governmental housing agency that receives funds under a contract with the grantee to provide eligible housing and other support services or administrative services as defined in 24 CFR 574.300. Project Sponsor organizations are required to provide performance data on households served and funds expended. Funding flows to a project sponsor as follows: HUD Funding > Grantee -> Project Sponsor Short -Term Rent, Mortgage, and Utility (STRMU) Assistance: A time -limited, housing subsidy assistance designed to prevent homelessness and increase housing stability. Grantees may provide assistance for up to 21 weeks in any 52 week period. The amount of assistance varies per client depending on funds available tenant need and program guidelines. Stewardship Units: Units developed with HOPWA, where HOPWA funds were used for acquisition, new construction and rehabilitation that no longer receive operating subsidies from HOPWA. Report information for the units is subject to the three-year use agreement if rehabilitation is non -substantial and to the ten-year use agreement if rehabilitation is substantial. Subrecipient Organization: Any organization that receives funds from a project sponsor to provide eligible housing and other support services and/or administrative services as defined in 24 CFR 574.300. If a subrecipient organization provides housing and/or other supportive services directly to clients, the subrecipient organization must provide performance data on household served and funds expended. Funding flows to subrecipients as follows: HUD Funding -> Grantee > Project Sponsor >Subrecipient Tenant -Based Rental Assistance (TBRA): TBRA is a rental subsidy program similar to the Housing Choice Voucher program that grantees can provide to help low-income households access affordable housing. The TBRA voucher is not tied to a specific unit, so tenants may move to a different unit without losing their assistance, subject to individual program rules. The subsidy amount is determined in part based on household income and rental costs associated with the tenant's lease. Transgender: Transgender is defined as a person who identifies with, or presents as, a gender that is different from his/her gender at birth. Veteran: A veteran is someone who has served on active duty in the Armed Forces of the United States. This does not include inactive military reserves or the National Guard unless the person was called up to active duty. Previous editions are obsolete Page iii form HUD-40110-D (Expiration Date: 10/31/2014) Housing Opportunities for Person with AIDS (HOPWA) Consolidated Annual Performance and Evaluation Report (CAPER) Measuring Performance Outputs and Outcomes OMB Number 2506-0133 (Expiration Date: 10/31/2014) 'Part 1: Grantee Executive Summary As applicable, complete the charts below to provide more detailed information about the agencies and organizations responsible for the administration and implementation of the HOPWA program. Chart 1 requests general Grantee Information and Chart 2 is to be completed for each organization selected or designated as a project sponsor, as defined by CFR 574 3 In Chart 3, indicate each subrecipient organization with a contract/agreement of $25,000 or greater that assists grantees or project sponsors carrying out their administrative or evaluation activities In Chart 4, indicate each subrecipient organization with a contract/agreement to provide HOPWA-funded services to client households These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006 (Public Law 109-282). Note: Please see the definition section for distinctions between project sponsor and subrecipient. Note: If any information does not apply to your organization, please enter N/A. Do not leave any section blank. 1. Grantee Information HUD Grant Number Grantee Name Business Address City, County, State, Zip Employer Identification Number (EIN) or Tax Identification Number (TIN) DUN & Bradstreet Number (DUNs): *Congressional District of Grantee's Business Address *Congressional District of Primary Service Area(s) *City(ies) and County(ies) of Primary Service Area(s) Organization s Website Address Cities: Operating Year for this report From (mm/dd/yy) To (mm/dd/yy) Central Contractor Registration (CCR): Is the grantee's CCR status currently active? 0 Yes 0 No If yes, prov'de CCR Number: Counties: Is there a waiting list(s) for HOPWA Housing Subs dy Assistance Services in the Grantee service Area? ❑ Yes ❑ No If yes, explain in the narrative section what services maintain a waiting list and how this list is administered. * Service delivery area information only needed for program activities being directly carried out by the grantee. Previous editions are obsolete Page 1 form HUD-40110-D (Expiration Date: 10/31/2014) 2 Project Sponsor Information Please complete Chart 2 for each organization designated or selected to serve as a project sponsor, as defined by CFR 574.3. Use this section to report on organizations involved in the direct delivery of services for client households These elements address requirements in the Federal Financial Accountability and Transparency Act of 2006 (Public Law 109-282). Note: Please see the definitions for distinctions between project sponsor and subrecipient. Note: If any information does not apply to your organization, please enter N/A. Project Sponsor Agency Name Name and Title of Contact at Project Sponsor Agency Email Address Business Address City, County, State, Zip, Phone Number (with area code) Employer Identification Number (EIN) or Tax Identification Number (TIN) DUN & Bradstreet Number (DUNs): Congressional District of Project Sponsor's Business Address Congressional District(s) of Primary Service Area(s) City(ies) and County(ies) of Primary Service Cities: Area(s) Total HOPWA contract amount for this Organization for the operating year Organization's Website Address Is the sponsor a nonprofit organization? ■ Yes ❑ No Please check if yes and a faith -based organization. ❑ Please check if yes and a grassroots organization. ❑ Parent Company Name, if applicable Fax Number (with area code) Counties: Does your organization maintain a waiting list? ❑ Yes ❑ No If yes, explain in the narrative section how this list is administered. Previous editions are obsolete Page 2 form HUD-40110-D (Expiration Date: 10/31/2014) 3. Administrative Subrecipient Information Use Chart 3 to provide the following information for each subrecipient with a contract/agreement of $25,000 or greater that assists project sponsors to carry out their administrative services but no services directly to client households Agreements include: grants, subgrants, loans, awards, cooperative agreements, and other forms of financial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders. (Organizations listed may have contracts with project sponsors) These elements address requirements in the Federal Funding and Accountability and Transparency Act of 2006 (Public Law 109- 282). Note: Please see the definitions for distinctions between project sponsor and Subrecipient. Note: If any information does not apply to your organization, please enter N/A. Subrecipient Name Name and Title of Contact at Subrecipient Email Address Business Address City, State, Zip, County Phone Number (with area code) Employer Identification Number (EIN) or Tax Identification Number (TIN) DUN & Bradstreet Number (DUNs): Parent Company Name, if applicable Fax Number (include area code) North American Industry Classification System (NAICS) Code Congressional District of Subrecipient's Business Address Congressional District of Primary Service Area City (ies) and County (ies) of Primary Service Cities: Counties: Area(s) Total HOPWA Subcontract Amount of this Organization for the operating year Previous editions are obsolete Page 3 form HUD-40110-D (Expiration Date: 10/31/2014) 4. Program Subrecipient Information Complete the following information for each subrecipient organization providing HOPWA-funded services to client households. These organizations would hold a contract/agreement with a project sponsor(s) to provide these services. For example, a subrecipient organization may receive funds from a project sponsor to provide nutritional services for clients residing within a HOPWA facility -based housing program. Please note that subrecipients who work directly with client households must provide performance data for the grantee to include m Parts 2-7 of the CAPER. Note: Please see the definition of a subrecipient for more information. Note: Types of contracts/agreements may include. grants, sub -grants, loans, awards, cooperative agreements, and other forms of financial assistance; and contracts, subcontracts, purchase orders, task orders, and delivery orders. Note: If any information is not applicable to the organization, please report N/A in the appropriate box. Do not leave boxes blank. Sub -recipient Name Name and Title of Contact at Contractor/ Sub -contractor Agency Email Address Business Address City, County, State, Zip Phone Number (included area code) Employer Identification Number (EIN) or Tax Identification Number (TIN) DUN & Bradstreet Number (DUNs) North American Industry Classification System (NAICS) Code Congressional District of the Sub -recipient's Business Address Congressional District(s) of Primary Service Area City(ies) and County(ies) of Primary Service Area Total HOPWA Subcontract Amount of this Organization for the operating year Cities: Parent Company Name, if applicable Fax Number (include area code) Counties: Previous editions are obsolete Page 4 form HUD-40110-D (Expiration Date: 10/31/2014) 5. Grantee Narrative and Performance Assessment a. Grantee and Community Overview Provide a one to three page narrative summarizing major achievements and highlights that were proposed and completed during the program year Include a brief description of the grant organization, area of service, the name(s) of the program contact(s), and an overview of the range/type of housing activities provided This overview may be used for public information, including posting on HUD's website. Note: Text fields are expandable. b. Annual Performance under the Action Plan Provide a narrative addressing each of the following four items. 1. Outputs Reported. Describe significant accomplishments or challenges in achieving the number of housing units supported and the number households assisted with HOPWA funds during this operating year compared to plans for this assistance as approved in the Consolidated Plan/Action Plan. Describe how HOPWA funds were distributed during your program year among different categories of housing and geographic areas to address needs throughout the grant service area, consistent with approved plans. 2. Outcomes Assessed. Assess your program's success in enabling HOPWA beneficiaries to establish and/or better maintain a stable living environment in housing that is safe, decent, and sanitary and improve access to care. Compare current year results to baseline results for clients Describe how program activities/projects contributed to meeting stated goals. If program did not achieve expected targets, please describe how your program plans to address challenges in program implementation and the steps currently being taken to achieve goals in next operating year If your program exceeded program targets, please describe strategies the program utilized and how those contributed to program successes. 3. Coordination. Report on program coordination with other mainstream housing and supportive services resources, including the use of committed leveraging from other public and private sources that helped to address needs for eligible persons identified in the Consolidated Plan/Strategic Plan. 4. Technical Assistance. Describe any program technical assistance needs and how they would benefit program beneficiaries. c. Barriers and Trends Overview Provide a narrative addressing items 1 through 3. Explain how barriers and trends affected your program's ability to achieve the objectives and outcomes discussed in the previous section ■ 1. Describe any barriers (including regulatory and non -regulatory) encountered in the administration or implementation of the HOPWA program, how they affected your program's ability to achieve the objectives and outcomes discussed, and, actions taken in response to barriers, and recommendations for program improvement. Provide an explanation for each HOPWA/HUD Regulations ❑ Planning ■ Housing Availability 0 Rent Determination and Fair Market Rents Discrimination/Confidentiality ❑ Multiple Diagnoses ❑ Eligibility 0 Technical Assistance or Training barrier selected. Previous editions are obsolete Page 5 form HUD-40110-D (Expiration Date: 10/31/2014) ❑ Supportive Services ❑ Housing Affordability ❑ Credit History ■ Rental History ❑ Geography/Rural Access ■ Other, please explain further 0 Criminal Justice History 2. Describe any trends in the community that may affect the way in which the needs of persons living with HIV/AIDS are being addressed, and provide any other information important to the future provision of services to this population. 3. Identify any evaluations, studies, or other assessments of the HOPWA program that are available to the public. d. Unmet Housing Needs: An Assessment of Unmet Housing Needs In Chart 1, provide an assessment of the number of HOPWA-eligible households that require HOPWA housing subsidy assistance but are not currently served by any HOPWA-funded housing subsidy assistance in this service area. In Row 1, report the total unmet need of the geographical service area, as reported in Unmet Needs for Persons with HIV/AIDS, Chart 1B of the Consolidated or Annual Plan(s) or as reported under HOPWA worksheet in the Needs Workbook of the Consolidated Planning Management Process (CPMP) tool. Note: Report most current data available, tin ough Consolidated or Annual Plan(s), and account for local housing issues, or changes in HIV/AIDS cases, by using combination of one or more of the sources in Chart 2. If data is collected on the type of housing that is needed in Rows a. through c., enter the number of HOPWA-eligible households by type of housing subsidy assistance needed For an approximate breakdown of overall unmet need by type of housing subsidy assistance refer to the Consolidated or Annual Plan (s), CPMP tool or local distribution of funds. Do not include clients who are already receiving HOPWA-funded housing subsidy assistance. Refer to Chart 2, and check all sources consulted to calculate unmet need. Reference any data from neighboring states' or municipalities' Consolidated Plan or other planning efforts that informed the assessment of Unmet Need in your service area. Note: In order to ensure that the unmet need assessment for the region rs comprehensive, HOPWA formula grantees should include those unmet needs assessed by HOPWA competitive grantees operating within the service area. 1. Planning Estimate of Area's Unmet Needs for HOPWA-Eligible Households 1. Total number of households that have unmet housing subsidy assistance need. Previous editions are obsolete Page 6 form HUD-40110-D (Expiration Date: 10/31/2014) 2. From the total reported in Row 1, identify the number of households with unmet housing needs by type of housing subsidy assistance: a. Tenant -Based Rental Assistance (TBRA) b. Short -Term Rent, Mortgage and Utility payments (STRMU) • Assistance with rental costs • Assistance with mortgage payments • Assistance with utility costs. c. Housing Facilities such as community residences, SRO dwellings, other housing facilities Previous editions are obsolete Page 7 form HUD-40110-D (Expiration Date: 10/31/2014) 2. Recommended Data Sources for Assessing Unmet Need (check all sources used) = Data as reported in the area Consolidated Plan, e.g. Table 1B CPMP charts, and related narratives = Data established by area HIV/AIDS housing planning and coordination efforts, e.g. Continuum of Care = Data from client information provided in Homeless Management Information Systems (HMIS) = Data from project sponsors or housing providers, including waiting lists for assistance or other assessments on need including those completed by HOPWA competitive grantees operating in the region. = Data from prisons or jails on persons being discharged with HIV/AIDS, if mandatory testing is conducted = Data from local Ryan White Planning Councils or reported in CARE Act Data Reports, e.g. number of clients with permanent housing = Data collected for HIV/AIDS surveillance reporting or other health assessments, e.g. local health department or CDC surveillance data End of PART 1 Previous editions are obsolete Page 8 form HUD-40110-D (Expiration Date: 10/31/2014) PART 2: Sources of Leveraging and Program Income i 1. Sources of Leveraging Report the source(s) of cash or in -kind leveraged federal, state, local or private resources identified in the Consolidated or Annual Plan and used in the delivery of the HOPWA program and the amount of leveraged dollars. In Column [1], identify the type of leveraging. Some common sources of leveraged funds have been provided as a reference point. You may add Rows as necessary to report all sources of leveraged funds. Include Resident Rent payments paid by clients directly to private landlords. Do NOT include rents paid directly to a HOPWA program as this will be reported in the next section. In Column [2] report the amount of leveraged funds expended during the operating year. Use Column [3] to provide some detail about the type of leveraged contribution (e.g., case management services or clothing donations). In Column [4], check the appropriate box to indicate whether the leveraged contribution was a housing subsidy assistance or another form of support. Note: Be sure to report on the number of households supported with these leveraged funds in Part 3, Chart 1, Column d. A. Source of Leveraging Chart [1] Source of Leveraging Public Funding Ryan White -Housing Assistance Ryan White -Other Housing Choice Voucher Program Low Income Housing Tax Credit HOME Shelter Plus Care Emergency Solutions Grant Other Public: Other Public: Other Public: Other Public: Other Public: [2] Amount of Leveraged Funds [3] Type of Contribution [4] Housing Subsidy Assistance or Other Support JHousing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Housing Subsidy Other Support Assistance Assistance Assistance Assistance Assistance Assistance Assistance Assistance Assistance Assistance Assistance Assistance Private Funding Grants In -kind Resources Other Private: Other Private: Housing Subsidy Assistance Other Support Housing Subsidy Assistance Other Support Housing Subsidy Assistance Other Support Housing Subsidy Assistance Other Support Other Funding Grantee/Project Sponsor/Subrecipient (Agency) Cash Resident Rent Payments by Client to Private Landlord TOTAL (Sum of all Rows) Housing Subsidy Assistance Other Su.. ort Previous editions are obsolete Page 9 form HUD-40110-D (Expiration Date: 10/31/2014) 2. Program Income and Resident Rent Payments In Section 2, Chart A., report the total amount of program income and resident rent payments directly generated from the use of HOPWA funds, including repayments. Include resident rent payments collected or paid directly to the HOPWA program. Do NOT include payments made directly from a client household to a private landlord. Note: Please see report directions section for definition of program income. (Additional information On program income is available in the HOPWA Grantee Oversight Resource Guide). A. Total Amount Program Income and Resident Rent Payment Collected During the Operating Year Program Income and Resident Rent Payments Collected Program income (e.g. repayments) Resident Rent Payments made directly to HOPWA Program . Total Program Income and Resident Rent Payments (Sum of Rows 1 and 2) Total Amount of Program Income (for this operating year) B. Program Income and Resident Rent Payments Expended To Assist HOPWA Households In Chart B, report on the total program income and resident rent payments (as reported above in Chart A) expended during the operating year. Use Row 1 to report Program Income and Resident Rent Payments expended on Housing Subsidy Assistance Programs (i.e., TBRA, STRMU, PHP Master Leased Units and Facility -Based Housing). Use Row 2 to report on the Program Income and Resident Rent Payment expended on Supportive Services and other non -direct Housing Costs. Program Income and Resident Rent Payment Expended on HOPWA programs Program Income and Resident Rent Payment Expended on Housing Subsidy Assistance costs 2. Program Income and Resident Rent Payment Expended on Supportive Services and other non - direct housing costs 3. Total Program Income Expended (Sum of Rows 1 and 2) End of PART 2 Total Amount of Program Income Expended (for this operating year) Previous editions are obsolete Page 10 form HUD-40110-D (Expiration Date: 10/31/2014) PART 3: Accomplishment Data Planned Goal and Actual Outputs In Chart 1, enter performance information (goals and actual outputs) for all activities undertaken during the operating year supported with HOPWA funds. Performance is measured by the number of households and units of housing that were supported with HOPWA or other federal, state local, or private funds for the purposes of providing housing assistance and support to persons living with HIV/AIDS and their families. Note: The total households assisted with HOPWA funds and reported in PART 3 of the CAPER should be the same as reported in the annual year-end IDIS data, and goals reported should be consistent with the Annual Plan information. Any discrepancies or deviations should be explained in the narrative section of PART 1. 1. HOPWA Performance Planned Goal and Actual Outputs HOPWA Performance Planned Goal and Actual IHOPWA Housing Subsidy Assistance 1. [Tenant -Based Rental Assistance a Permanent Housing Facilities: 'Received Operating Subsidies/Leased units (Households Served) 2b. ransitionallShort-term Facilities: eceived Operating Subsidies/Leased units (Households Served) Households Served) 3a. (Permanent Housing Facilities: apital Development Projects placed in service during the operating year Households Served) 3b. Transitional/Short-term Facilities: Capital Development Projects placed in service during the operating year (Households Served) 14. Short -Term Rent, Mortgage and Utility Assistance 5. rermanent Housing Placement Services 6. Adjustments for duplication (subtract) 7. Total HOPWA Housing Subsidy Assistance {Columns a. — d. equal the sum of Rows 1-5 minus Row 6; Columns e. and f. equal the sum of Rows 1-5) Housing Development (Construction and Stewardship of facility based housing) 8. Facility -based units; Capital Development Projects not yet opened (Housing Units) V[Stewardship Units subject to 3 or 10 year use agreements 10. Total Housing Developed (Sum of Rows 78 & 9) !Supportive Services 11a.Supportive Services provided by project sponsors/subrecipient that also delivered OPWA housing subsidy assistance l lb Supportive Services provided by project sponsors/subrecipient that only provided supportive services. 12. 'Adjustment for duplication (subtract) 13. Ilrf'otal Supportive Services Columns a. — d. equal the sum of Rows 11 a. & b. minus Row 12; Columns e. and f. qual the sum of Rows lia. & 11b.) Housing Information Services 14. 'Housing Information Services 115. 'Housing Housing Information Services ( [1] Output: Households [2] Output: Funding HOPWA Leveraged Assistance Households a. b. HOPWA Funds d. e. f. ob 714 x z x (1 Output: Households 121 Output: Funding 111 Output: Housing Units 111 Output Households 121 Output: Funding 121 Output: Funding: 11] Output Households 121 Output: Funding Previous editions are obsolete Page 11 form HUD-40110-D (Expiration Date: 10/31/2014) 20. Grant Administration and Other Activities 16. Resource Identification to establish, coordinate and develop housing assistance resources 17. Technical Assistance (if approved in grant agreement) 18. Grantee Administration (maximum 3% of total HOPWA grant) 19. Project Sponsor Administration (maximum 7% of portion of HOPWA grant awarded) Total Grant Administration and Other Activities (Sum of Rows 16 —19) Total Expended 121.'Total Expenditures for program year (Sum of Rows 7,10,13,15, and 20) ]l� Output Households [2] Output: Funding 2] Outputs: HOPWA Funds Expended Budget Actual 2. Listing of Supportive Services Report on the households served and use of HOPWA funds for all supportive services. Do NOT report on supportive services leveraged with non-HOPWA funds. Data check: Total unduplicated households and expenditures reported in Row 17 equal totals reported in Part 3, Chart 1, Row 13. Supportive Services 1. Adult day care and personal assistance 2. Alcohol and drug abuse services 3. Case management 4. Child care and other child services 5. Education 6. Employment assistance and training Health/medical/intensive care services, if approved 7. Note Client records must conform with 24 CFR §574.310 8. Legal services 9. Life skills management (outside of case management) 10. Meals/nutritional services 11. Mental health services 12. Outreach 13. Transportation Other Activity (if approved in grant agreement). 14. Specify: Sub -Total Households receiving Supportive Services 15. (Sum of Rows 1-14) 16. Adjustment for Duplication (subtract) TOTAL Unduplicated Households receiving Supportive Services (Column [11 equals Row 15 17. minus Row 16; Column ]2] equals sum of Rows 1-14) 111 Output: Number of Households [2] Output: Amount of HOPWA Funds Expended Previous editions are obsolete Page 12 form HUD-40110-D (Expiration Date: 10/31/2014) 3. Short -Term Rent, Mortgage and Utility Assistance (STRMU) Summary In Row a., enter the total number of households served and the amount of HOPWA funds expended on Short -Term Rent, Mortgage and Utility (STRMU) Assistance. In Row b., enter the total number of STRMU-assisted households that received assistance with mortgage costs only (no utility costs) and the amount expended assisting these households In Row c., enter the total number of STRMU-assisted households that received assistance with both mortgage and utility costs and the amount expended assisting these households In Row d., enter the total number of STRMU-assisted households that received assistance with rental costs only (no utility costs) and the amount expended assisting these households In Row e., enter the total number of STRMU-assisted households that received assistance with both rental and utility costs and the amount expended assisting these households. In Row f., enter the total number of STRMU-assisted households that received assistance with utility costs only (not including rent or mortgage costs) and the amount expended assisting these households. In row g. report the amount of STRMU funds expended to support direct program costs such as program operation staff. Data Check: The total households reported as served with STRMU in Row a., column [1] and the total amount of HOPWA finds reported as expended in Row a., column [2] equals the household and expenditure total reported for STRMU in Part 3, Chart 1, Row 4, Columns b. and f., respectively. Data Check: The total number of households reported in Column [1], Rows b., c., d, e., and f. equal the total number of STRAW households reported in Column [1], Row a. The total amount reported as expended in Column [2], Rows b., c., d., e., f, and g. equal the total amount of STRAIU expenditures reported in Column [2], Row a. Housing Subsidy Assistance Categories (STRMU) Total Short-term mortgage, rent and/or utility (STRMU) a. assistance Of the total STRMU reported on Row a total who received b• assistance with mortgage costs ONLY. Of the total STRMU reported on Row a. total who received c• assistance with mortgage and utility costs. Of the total STRMU reported on Row a, total who received d• assistance with rental costs ONLY. e. f. g. Of the total STRMU reported on Row a. total who received assistance with rental and utility costs. Of the total STRMU reported on Row a. total who received assistance with utility costs ONLY. Direct program delivery costs (e.g., program operations staff time) [1] Output: Number of Households Served End of PART 3 [2] Output: Total HOPWA Funds Expended on STRMU during Operating Year Previous editions are obsolete Page 13 form HUD-40110-D (Expiration Date: 10/31/2014) (Part 4: Summary of Performance Outcomes In Column [1], report the total number of eligible households that received HOPWA housing subsidy assistance, by type. In Column [2], enter the number of households that continued to access each type of housing subsidy assistance into next operating year. In Column [3], report the housing status of all households that exited the program. Data Check: The sun: of Coluf ins [2] (Number of Households Continuing) and [3] (Exited Households) equals the total reported in Colurnn[1J. Note: Refer to the housing stability codes that appear in Part 5: Wot ksheet - Determining Housing Stability Outcomes. Section 1. Housing Stability: Assessment of Client Outcomes on Maintaining Housing Stability (Permanent Housing and Related Facilities) A. Permanent Housing Subsidy Assistance Tenant -Based Rental Assistance Permanent Supportive Housing Facilities/ Units B. Transitiona Transitional/ Short -Term Housing Facilities/ Units [1] Output: Total Number of Households Served Housing Assistance [1] Output: Total Number of Households Served [2] Assessment: Number of Households that Continued Receiving HOPWA Housing Subsidy Assistance into the Next Operating Year [2] Assessment: Number of Households that Continued Receiving HOPWA Housing Subsidy Assistance into the Next Operating Year [3] Assessment: Number of Households that exited this HOPWA Program; their Housing Status after Exiting I Emergency Shelter/Streets 2 Temporary Housing 3 Private Housing 4 Other HOPWA 5 Other Subsidy 6 Institution 7 Jail/Prison 8 Disconnected/Unknown 9 Death 1 Emergency Shelter/Streets 2 Temporary Housing 3 Private Housing 4 Other HOPWA 5 Other Subsidy 6 Institution 7 Jail/Prison 8 Disconnected/Unknown 9 Death [3] Assessment: Number of Households that exited this HOPWA Program, their Housing Status after Exiting I Emergency Shelter/Streets 2 Temporary Housing 3 Private Housing 4 Other HOPWA 5 Other Subsidy 6 Institution 7 Jail/Prison 8 Disconnected/unknown 9 Death [4] HOPWA Client Outcomes Unstable Arrangements Temporarily Stable, with Reduced Risk of Homelessness Stable/Permanent Housing (PH) Unstable Arrangements Life Event Unstable Arrangements Temporarily Stable, with Reduced Risk of Homelessness Stable/Permanent Housing (PH) Unstable Arrangements Life Event [4] HOPWA Client Outcomes Unstable Arrangements Temporarily Stable with Reduced Risk of Homelessness Stable/Permanent Housing (PH) Unstable Arrangements Life Event Previous editions are obsolete Page 14 form HUD-40110-D (Expiration Date: 10/31/2014) B 1:Total number of households receiving transitional/short-term housing assistance whose tenure exceeded 24 months Section 2. Prevention of Homelessness: Assessment of Client Outcomes on Reduced Risks of Homelessness (Short -Term Housing Subsidy Assistance) Report the total number of households that received STRMU assistance in Column [1]. In Column [2] identify the outcomes of the households reported in Column [1] either at the time that they were known to have left the STRMU program or through the project sponsor or subrecipient's best assessment for stability at the end of the operating year. Information in Column [3] provides a description of housing outcomes, therefore, data is not required At the bottom of the chart • In Row 1 a., report those households that received STRMU assistance during the operating year of this report, and the prior operating year. • In Row lb. report those households that received STRMU assistance during the operating year of this report, and the two prior operating years. Data Check: The total households reported as served with STRMU in Coluinn [1] equals the total reported in Part 3, Chart 1, Row 4, Column b. Data Check: The sum of Column [21 should equal the number of households reported in Column [1]. Assessment of Households that Received STRMU Assistance [1] Output: Total [2] Assessment of Housing Status number of households Maintain Private Housing without subsidy (e.g. Assistance provided/completed and client is stable, not likely to seek additional support) Other Private Housing without subsidy (e.g. client switched housing units and is now stable, not likely to seek additional support) Other HOPWA Housing Subsidy Assistance Other Housing Subsidy (PH) Institution (e.g. residential and long-term care) Likely that additional STRMU is needed to maintain current housing arrangements Transitional Facilities/Short-term (e.g. temporaey or transitional arrangement) Temporary/Non-Permanent Housing arrangement (e.g. gave up lease, and moved in with family or friends but expects to live there less than 90 days) Emergency Shelter/street Jail/Prison Disconnected Death [3] HOPWA Client Outcomes Stable/Permanent Housing (PH) Temporarily Stable, with Reduced Risk of Homelessness o i Unstable Arrangements la. Total number of those households that received STRMU Assistance in the operating year of this report that also received STRMU assistance in the prior operating year (e.g. households that received STRMU assistance in two consecutive operating years). lb. Total number of those households that received STRMU Assistance in the operating year of this report that also received STRMU assistance in the two prior operating years (e.g. households that received STRMU assistance in three consecutive operating years). Life Event Previous editions are obsolete Page 15 form HUD-40110-D (Expiration Date: 10/31/2014) Section 3. HOPWA Outcomes on Access to Care and Support la. Total Number of Households Line [1]: For project sponsors/subrecipients that provided HOPWA housing subsidy assistance during the operating year ident fy in the appropriate row the number of households that received HOPWA housing subsidy assistance (TBRA, STRMU, Facility -Based PHP and Master Leasing) and HOPWA funded case management services. Use Row c. to adjust for duplication among the service categories and Row d. to provide an unduplicated household total. Line [2]: For project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance identify in the appropriate row the number of households that received HOPWA funded case management services. Note: These numbers will help you to determine which clients to report Access to Care and Support Outcomes for and will be used by HUD as a basis for analyzing the percentage of households who demonstrated or maintained connections to care and support as identified in Chart lb. below. Total Number of Households 1. For Project Sponsors/Subrecipients that provided HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded services: a. Housing Subsidy Assistance (duplicated)-TBRA, STRMU, PHP, Facility -Based Housing, and Master Leasing b. Case Management c. Adjustment for duplication (subtraction) d. Total Households Served by Project Sponsors/Subrecipients with Housing Subsidy Assistance (Sum of Rows a.b. minus Row c.) 2. For Project Sponsors/Subrecipients did NOT provide HOPWA Housing Subsidy Assistance: Identify the total number of households that received the following HOPWA-funded service* a. HOPWA Case Management b. Total Households Served by Project Sponsors/Subrecipients without Housing Subsidy Assistance lb. Status of Households Accessing Care and Support Column [1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA housing subsidy assistance as identified in Chart 1 a., Row 1 d. above, report the number of households that demonstrated access or maintained connections to care and support within the program year. Column [2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance as reported in Chart 1 a., Row 2b., report the number of households that demonstrated improved access or maintained connections to care and support within the program year. Note: For information on types and sources of income and medical insurance/assistance, refer to Charts below. [2] For project sponsors/subrecipients that did NOT provide HOPWA Outcome housing subsidy assistance, Indicator identify the households who demonstrated the following: Categories of Services Accessed 1. Has a housing plan for maintaining or establishing stable on- going housing 2. Had contact with case manager/benefits counselor consistent with the schedule specified in client's individual service plan (may include leveraged services such as Ryan White Medical Case Management) 3. Had contact with a primary health care provider consistent with the schedule specified in client's individual service plan 4. Accessed and maintained medical insurance/assistance 5. Successfully accessed or maintained qualification for sources of income [1] For project sponsors/subrecipients that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following: Support for Stable Housing Access to Support Access to Health Care Access to Health Care Sources of Income Previous editions are obsolete Page 16 form HUD-40110-D (Expiration Date: 10/31/2014) Chart lb., Line 4: Sources of Medical Insurance and Assistance include, but are not limited to the following (Reference only) • MEDICAID Health Insurance Program, or • Veterans Affairs Medical Services use local program • AIDS Drug Assistance Program (ADAP) name • State Children's Health Insurance Program • MEDICARE Health Insurance Program, or (SCHIP) or use local program name use local program name • Ryan White -funded Medical or Dental Assistance Chart lb., Row 5: Sources of Income include, but are not limited to the following (Reference only) • Earned Income • Veteran's Pension • Unemployment Insurance • Pension from Former Job • Supplemental Security Income (SSI) • Child Support • Social Security Disability Income (SSDI) • Alimony or other Spousal Support • Veteran's Disability Payment • Retirement Income from Social Security • Worker's Compensation • General Assistance (GA), or use local program name • Private Disability Insurance • Temporary Assistance for Needy Families (TANF) • Other Income Sources lc. Households that Obtained Employment Column [1]: Of the households identified as receiving services from project sponsors/subrecipients that provided HOPWA housing subsidy assistance as identified in Chart la., Row ld. above, report on the number of households that include persons who obtained an income -producing job during the operating year that resulted from HOPWA-funded Job training, employment assistance, education or related case management/counseling services Column [2]: Of the households identified as receiving services from project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance as reported in Chart la., Row 2b., report on the number of households that include persons who obtained an income -producing job during the operating year that resulted from HOPWA-funded Job training, employment assistance, education or case management/counseling services. Note: This includes jobs created by this project sponsor/subrecipients or obtained outside this agency. Note: Do not include jobs that resulted from leveraged job training, employment assistance, education or case management/counseling services. Categories of Services Accessed Total number of households that obtained an income -producing job [1 For project sponsors/subrecipients that provided HOPWA housing subsidy assistance, identify the households who demonstrated the following: End of PART 4 [2] For project sponsors/subrecipients that did NOT provide HOPWA housing subsidy assistance, identify the households who demonstrated the following: Previous editions are obsolete Page 17 form HUD-40110-D (Expiration Date: 10/31/2014) IPART 5: Worksheet - Determining Housing Stability Outcomes (optional) 1. This chart is designed to assess program results based on the information reported in Part 4 and to help Grantees determine overall program performance. Completion of this worksheet is optional. Permanent Stable Housing Temporary Housing Unstable Life Event Housing Subsidy (# of households (2) Arrangements (9) Assistance remaining in program (1+7+8) plus 3+4+5+6) 1 Tenant -Based Rental Assistance (TBRA) Permanent Facility - based Housing Assistance/Units Transitional/Short- Term Facility -based Housing Assistance/Units Total Permanent HOPWA Housing Subsidy Assistance Reduced Risk of Homelessness: Short -Term Assistance Short -Term Rent, Mortgage, and Utility Assistance (STRMU) Total HOPWA Housing Subsidy Assistance * Stable/Permanent Housing ur 14 If if 7 Temporarily Stable, with Reduced Risk of Unstable Life Events Homelessness Arrangements Background on HOPWA Housing Stability Codes Stable Permanent Housing/Ongoing Participation 3 = Private Housing in the private rental or home ownership market (without known subsidy, including permanent placement with families or other self-sufficient arrangements) with reasonable expectation that additional support is not needed. 4 = Other HOPWA-funded housing subsidy assistance (not STRMU), e.g TBRA or Facility -Based Assistance. 5 = Other subsidized house or apartment (non-HOPWA sources, e.g., Section 8, HOME, public housing). 6 = Institutional setting with greater support and continued residence expected (e g., residential or long-term care facility). Temporary Housing 2 = Temporary housing - moved in with family/friends or other short-term arrangement, such as Ryan White subsidy, transitional housing for homeless, or temporary placement in institution (e.g. hospital, psychiatric hospital or other psychiatric facility, substance abuse treatment facility or detox center). Unstable Arrangements 1 = Emergency shelter or no housing destination such as places not meant for habitation (e.g., a vehicle, an abandoned building, bus/train/subway station, or anywhere outside). 7 = Jail /prison. 8 = Disconnected or disappeared from project support, unknown destination or no assessments of housing needs were undertaken Life Event 9 = Death, i.e., remained in housing until death. This characteristic is not factored into the housing stability equation Tenant -based Rental Assistance: Stable Housine is the sum of the number of households that (i) remain in the housing and (ii) those that left the assistance as reported under: 3, 4, 5, and 6. Temporary Housing is the number of households that accessed assistance, and left their current housing for a non -permanent housing arrangement, as reported under item* 2 Unstable Situations is the sum of numbers reported under items: 1, 7, and 8. 1 Previous editions are obsolete Page 18 form HUD-40110-D (Expiration Date: 10/31/2014) Permanent Facility -Based Housing Assistance: Stable Housing is the sum of the number of households that (i) remain in the housing and (ii) those that left the assistance as shown as items. 3, 4, 5, and 6. Temporary Housing is the number of households that accessed assistance, and left their current housing for a non -permanent housing arrangement, as reported under item 2 Unstable Situations is the sum of numbers reported under items. 1, 7, and 8. Transitional/Short-Term Facility -Based Housing Assistance: Stable Housing is the sum of the number of households that (i) continue in the residences (ii) those that left the assistance as shown as items. 3, 4, 5 and 6 Other Temporary Housing is the number of households that accessed assistance, and Left their current housing for a non -permanent housing arrangement, as reported under item 2 Unstable Situations is the sum of numbers reported under items. 1, 7, and 8. Tenure Assessment. A baseline of households in transitional/short-term facilities for assessment purposes, indicate the number of households whose tenure exceeded 24 months. STRMU Assistance: Stable Housing is the sum of the number of households that accessed assistance for some portion of the permitted 21-week period and there is reasonable expectation that additional support is not needed in order to maintain permanent housing living situation (as this is a time -limited form of housing support) as reported under housing status: Maintain Private Housing with subsidy; Other Private with Subsidy; Other HOPWA support; Other Housing Subsidy; and Institution. Temporarily Stable with Reduced Risk of Homelessness is the sum of the number of households that accessed assistance for some portion of the permitted 21-week period or left their current housing arrangement for a transitional facility or other temporary/non-permanent housing arrangement and there is reasonable expectation additional support will be needed to maintain housing arrangements in the next year, as reported under housing status: Likely to maintain current housing arrangements, with additional STRMU assistance; Transitional Facilities/Short-term; and Temporary/Non-Permanent Housing arrangements Unstable Situation is the sum of number of households reported under housing status: Emergency Shelter Jail/Prison; and Disconnected. End of PART 5 Previous editions are obsolete Page 19 form HUD-40110-D (Expiration Date: 10/31/2014) (PART 6: Annual Certification of Continued Usage for ITOPWA Facility -Based Stewardship Units (ONLY) The Annual Certification of Usage for HOPWA Facility -Based Stewardship Units is to be used in place of Part 7B of the CAPER if the facility was originally acquired, rehabilitated or constructed/developed in part with HOPWA funds but no HOPWA funds were expended during the operatmg year. Scattered site units may be grouped together on one page. Grantees that used HOPWA funding for new construction, acquisition, or substantial rehabilitation are required to operate their facilities for HOPWA eligible individuals for at least ten (10) years. If non -substantial rehabilitation funds were used they are required to operate for at least three (3) years. Stewardship begins once the facility is put into operation Note: See definition of Stewardship Units. 1. General information HUD Grant Number(s) Grantee Name 2. Number of Units and Non-HOPWA Expenditures Facility Name: Total Stewardship Units (subject to 3- or 10- year use periods) Number of Stewardship Units Developed with HOPWA funds Operating Year for this report From (n:m/dd/}y) To (n m/dd/yy) ❑ Final Yr ❑ Yr 1; ❑ Yr 2• ❑ Yr 3; ■ Yr 46 ❑ Yr 5; ❑ Yr 6; ❑ Yr 7; ❑ Yr 8; ❑ Yr 9; ❑ Yr 10; Date Facility Began Operations (n m/dd/yy) Amount of Non-HOPWA Funds Expended in Support of the Stewardship Units during the Operating Year 3. Details of Project Site Project Sites: Name of HOPWA-funded project Site Information: Project Zip Code(s) Site Information: Congressional District(s) Is the address of the project site confidential? 0 Yes, protect information; do not list ❑ Not confidential; information can be made available to the public If the site is not confidential: Please provide the contact information, phone, email address/location, if business address is different from facility address I certify that the facility that received assistance for acquisition, rehabilitation, or new construction from the Housing Opportunities for Persons with AIDS Program has operated as a facility to assist HOPWA-eligible persons from the date shown above. I also certify that the grant is still serving the planned number of HOPWA-eligible households at this facility through leveraged resources and all other requirements of the grant agreement are being satisfied. r I hereby certify that all the information stated herein, as well as any information provided in the accompaniment herewith, is true and accurate. Name & Title of Authorized Official of the organization that continues Signature & Date (mm/dd/yy) to operate the facility: Name & Title of Contact at Grantee Agency Contact Phone (with area code) (person who can answer questions about the report and program) End of PART 6 1 Previous editions are obsolete Page 20 form HUD-40110-D (Expiration Date: 10/31/2014) Part 7: Summary Overview of Grant Activities A. Information on Individuals, Beneficiaries, and Households Receiving HOPWA Housing Subsidy Assistance (TBRA, STRMU, Facility -Based Units, Permanent Housing Placement and Master Leased Units ONLY) Note: Reporting for this section should include ONLY those individuals, beneficiaries, w households that received and/or resided in a household that received HOPWA Housing Subsidy Assistance as reported in Part 3, Chart 1, Row 7, Cohann b. (e.g., do not include households that received HOPWA supportive services ONLY). Section 1. HOPWA-Eligible Individuals who Received HOPWA Housing Subsidy Assistance a. Total HOPWA Eligible Individuals Living with HIV/AIDS In Chart a., provide the total number of eligible (and unduplicated) low-income individuals living with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance during the operating year. This total should include only the individual who qualified the household for HOPWA assistance, NOT all HIV positive individuals in the household. Individuals Served with Housing Subsidy Assistance Total Number of individuals with HIV/AIDS who qualified their household to receive HOPWA housing subsidy assistance. Chart b. Prior Living Situation In Chart b., report the prior living situations for all Eligible Individuals reported in Chart a. In Row 1, report the total number of mdividuals who continued to receive HOPWA housing subsidy assistance from the prior operating year into this operating year In Rows 2 through 17, indicate the prior living arrangements for all new HOPWA housing subsidy assistance recipients during the operating year Data Check: The total number of eligible individuals served in Row 18 equals the total number of individuals served through housing subsidy assistance reported in Chart a. above. Category 1. I Continuing to receive HOPWA support from the prior operating year New Individuals who received HOPWA Housing Subsidy Assistance support during Operating Year 2 Place not meant for human habitation (such as a vehicle, abandoned building, bus/train/subway station/airport, or outside) 3. Emergency shelter (including hotel, motel, or campground paid for with emergency shelter voucher) 4. Transitional housing for homeless persons 5. Total number of new Eligible Individuals who received HOPWA Housing Subsidy Assistance with a Prior Living Situation that meets HUD definition of homelessness (Sum of Rows 2 — 4) 6 Permanent housing for formerly homeless persons (such as Shelter Plus Care, SHP, or SRO Mod Rehab) 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Psychiatric hospital or other psychiatric facility Substance abuse treatment facility or detox center Hospital (non -psychiatric facility) Foster care home or foster care group home Jail, prison or juvenile detention facility Rented room, apartment, or house House you own Staying or living in someone else's (family and friends) room, apartment, or house Hotel or motel paid for without emergency shelter voucher Other Don't Know or Refused TOTAL Number of HOPWA Eligible Individuals (sum of Rows 1 and 5-17) Total HOPWA Eligible Individuals Receiving Housing Subsidy Assistance Previous editions are obsolete Page 21 form HUD-40110-D (Expiration Date: 10/31/2014) c. Homeless Individual Summary In Chart c., indicate the number of eligible individuals reported in Chart b., Row 5 as homeless who also are homeless Veterans and/or meet the definition for Chronically Homeless (See Definition section of CAPER). The totals in Chart c. do not need to equal the total in Chart b., Row 5. Category HOPWA eligible individuals served with HOPWA Housing Subsidy Assistance Number of Homeless Veteran(s) Number of Chronically Homeless Section 2. Beneficiaries In Chart a., report the total number of HOPWA eligible individuals living with HIV/AIDS who received HOPWA housing subsidy assistance (as reported in Part 7A Section 1 Char t a.), and all associated members of their household who benefitted from receiving HOPWA housing subsidy assistance (resided with HOPWA eligible individuals). Note: See definition of HOPWA Eligible Individual Note: See definition of Transgender. Note: See definition of Beneficiaries. Data Check: The sawn of each of the Charts b. & c. on the following two pages equals the total number of beneficiaries served with HOPWA housing subsidy assistance as determined in Chart a., Row 4 below. a. Total Number of Beneficiaries Served with HOPWA Housing Subsidy Assistance Individuals and Families Served with HOPWA Housing Subsidy Assistance 1. Number of individuals with HIV/AIDS who qualified the household to receive HOPWA housing subsidy assistance (equals the number of HOPWA Eligible Individuals reported in Part 7A Section 1 Chart a.) 2. Number of ALL other persons diagnosed as HIV positive who reside with the HOPWA eligible individuals identified in Row 1 and who benefitted from the HOPWA housing subsidy assistance 3. Number of ALL other persons NOT diagnosed as HIV positive who reside with the HOPWA eligible individual identified in Row 1 and who benefited from the HOPWA housing subsidy 4. TOTAL number of ALL beneficiaries served with Housing Subsidy Assistance (Sum of Rows 1,2, & 3) 1 Total Number Previous editions are obsolete Page 22 form HUD-40110-D (Expiration Date: 10/31/2014) b. Age and Gender In Chart b., indicate the Age and Gender of all beneficiaries as reported in Chart a. directly above. Report the Age and Gender of all HOPWA Eligible Individuals (those reported in Chart a., Row 1) using Rows 1-5 below and the Age and Gender of all other beneficiaries (those reported in Chart a., Rows 2 and 3) using Rows 6-10 below. The number of individuals reported in Row 11, Column E. equals the total number of beneficiaries reported in Part 7, Section 2, Chart a., Row 4. Under 18 2. 18 to 30 years 3. 4. 5. 9. 10. 11. 31 to 50 years 51 years and Older Subtotal (Sum of Rows 1-4) Under 18 18 to 30 years 31 to 50 years 51 years and Older Subtotal (Sum of Rows 6-9) TOTAL (Sum of Rows 5 & 10) A. HOPWA Eligible Individuals (Chart a, Row 1) B. C. D. E. TOTAL (Sum of Male Female Transgender M to F Transgender F to M Columns A-D) All Other Beneficiaries (Chart a, Rows 2 and 3) A. B. C. Male D. E. TOTAL (Sum of Female Transgender M to F Transgender F to M Columns A-D) Total Beneficiaries (Chart a, Row 4) Previous editions are obsolete Page 23 form HUD-40110-D (Expiration Date: 10/31/2014) c. Race and Ethnicity* In Chart c , indicate the Race and Ethnicity of all beneficiaries receiving HOPWA Housing Subsidy Assistance as reported in Section 2, Chart a , Row 4. Report the race of all HOPWA eligible individuals in Column [A] Report the ethnicity of all HOPWA eligible individuals in column [B]. Report the race of all other individuals who benefitted from the HOPWA housing subsidy assistance in column [C]. Report the ethnicity of all other individuals who benefitted from the HOPWA housing subsidy assistance in column [D]. The summed total of columns [A] and [C] equals the total number of beneficiaries reported above in Section 2, Chart a., Row 4. Category 1. American Indian/Alaskan Native 2. Asian 3. Black/African American 4. Native Hawaiian/Other Pacific Islander 5. White 6. American Indian/Alaskan Native & White 7. Asian & White 8. Black/African American & White 9. American Indian/Alaskan Native & Black/African American 10. Other Multi -Racial 11. Column Totals (Sum of Rows 1-10) HOPWA Ehgible Individuals [A] Race [all individuals reported in Section 2, Chart a., Row 1] [B] Ethnicity [Also identified as H spanic or Latino] All Other Beneficiaries [C] Race [total of ind'viduals reported in Section 2, Chart a., Rows 2 & 3] [D] Ethnicity [Also identified as Hispanic or Latino] Data Check: Senn of Row 11 Column A and Row 11 Column C equals the total number HOPWA Beneficiaries reported in Pat t 3A, Section 2, Chart a., Row 4. *Reference (data requested consistent with Form HUD-27061 Race and Ethnic Data Reporting Form) Section 3. Households Household Area Median Income Report the area median income(s) for all households served with HOPWA housing subsidy assistance. Data Check: The total number of households served with HOPWA housing subsidy assistance should equal Part 3C, Row 7, Colnnn b and Part 7A, Section 1, Chart a. (Total HOPWA Eligible Individuals Served with HOPWA Housing Subsidy Assistance). Note: Refer to httv://www huduser.org/portal/datasets/il/i12010/select Geography iq l.odn for information on area median income in your community 1. 2. 3. 4. Percentage of Area Median Income 0-30% of area median income (extremely low) 31-50% of area median income (very low) 51-80% of area median income (low) Total (Sum of Rows 1-3) Households Served with HOPWA Housing Subsidy Assistance Previous editions are obsolete Page 24 form HUD-40110-D (Expiration Date: 10/31/2014) Part 7: Summary Overview of Grant Activities B. Facility -Based Housing Assistance Complete one Part 7B for each facility developed or supported through HOPWA funds. Do not complete this Section for programs originally developed with HOPWA funds but no longer supported with HOPWA funds. If a facility was developed with HOPWA funds (subject to ten years of operation for acquisition, new construction and substantial rehabilitation costs of stewardship units, or three years for non -substantial rehabilitation costs), but HOPWA funds are no longer used to support the facility, the project sponsor or subrecipient should complete Part 6: Annual Certification of Continued Usage for HOPWA Facility -Based Stewardship Units (ONLY). Complete Charts 2a. Project Site Information and 2b., Type of HOPWA Capital Development Project Units, for all Development Projects, including facilities that were past development projects, but continued to receive HOPWA operating dollars this reportmg year. 1. Project Sponsor/Subrecipient Agency Name (Required) 2. Capital Development 2a. Project Site Information for HOPWA Capital Development of Projects (For Current or Past Capital Development Projects that receive HOPWA Operating Costs this reporting year) Note: If units are scattered -sites, report on them as a group and under type of Facility write `Scattered Sites." Name of Facility: Type of Development this operating year ❑ New construction ■ Rehabilitation Acquisition Operating HOPWA Funds Expended this operating year (if applicable) $ $ a. Purchase/lease of property: b. Rehabilitation/Construction Dates: c. Operation dates: e. f. g• h. Non-HOPWA funds Expended (if applicable) Date supportive services began: Number of units in the facility: Is a waiting list maintained for the facility? What is the address of the facility (if different from business address)? Is the address of the project site confidential? Type of Facility [Check only one box.] ❑ Permanent housing ❑ Short-term Shelter or Transitional housing ❑ Supportive services only facility Date (mm/dd/yy): Date started: Date residents began to occupy: ❑ Not yet occupied Date started: D Not yet providing services Date Completed: HOPWA-funded units = Total Units = ❑ Yes ■ No If yes, number of participants on the list at the end of operating year ■ Yes, protect it formation; do not publish list ❑ No, can be made available to the public Previous editions are obsolete Page 25 form HUD-40110-D (Expiration Date: 10/31/2014) 2b. Number and Type of HOPWA Capital Development Project Units (For Current or Past Capital Development Projects that receive HOPWA Operating Costs this Reporting Year) For units entered above in 2a. please list the number of HOPWA units that fulfill the following criteria: Number Designated Number for the Chronically Designated to Number Energy- Number 504 Accessible Homeless Assist the Star Compliant Homeless Rental units constructed (new) and/or acquired with or without rehab Rental units rehabbed Homeownership units constructed (if approved) 3. Units Assisted in Types of Housing Facility/Units Leased by Project Sponsor or Subrecipient Charts 3a., 3b. and 4 are required for each facility. In Charts 3a. and 3b., indicate the type and number of housing units in the facility, including master leased units, project -based or other scattered site units leased by the organization, categorized by the number of bedrooms per unit. Note: The number units may not equal the total number of households served. Please complete separate charts for each housing facility assisted. Scattered site units may be grouped together. 3a. Check one only ❑ Permanent Supportive Housing Facility/Units ❑ Short-term Shelter or Transitional Supportive Housing Facility/Units 3b. Type of Facility Complete the following Chart for all facilities leased, master leased, project -based, or operated with HOPWA funds during the reportmg year Name of Project Sponsor/Agency Operating the Facility/Leased Units: Total Number of Units in use during the Operating Year Type of housing facility operated by the Categorized by the Number of Bedrooms per Units project sponsor/subrecipient SRO/Studio/0 1 bdrm 2 bdrm 3 bdrm 4 bdrm 5+bdrm bdrm a. Single room occupancy dwelling b. Community residence c. Project -based rental assistance units or leased units d. Other housing facility Specify: 4. Households and Housing Expenditures Enter the total number of households served and the amount of HOPWA funds expended by the project sponsor/subrecipient on subsidies for housing involving the use of facilities, master leased units, project based or other scattered site units leased by the organization. Housing Assistance Category: Facility Based Housing a. Leasing Costs Operating Costs Project -Based Rental Assistance (PBRA) or other leased units Other Activity (if approved in grant agreement) Specify: Adjustment to eliminate duplication (subtract) TOTAL Facility -Based Housing Assistance (Sum Rows a. through d. minus Row e.) Output: Number of Output: Total HOPWA Funds Expended during Households Operating Year by Project Sponsor/subrecipient Previous editions are obsolete Page 26 form HUD-40110-D (Expiration Date: 10/31/2014) EXHIBIT "I" MBE REPORTING FORM HOPWA PSA CONTRACT 2015-2016 -- EXHIBIT "I" -- MBE REPORTING FORM Page 1 Tarrant County Samaritan Housing, Inc. Contract and Subcontract Activity U.S. Department of Housing and Urban Development OMB Approval No.: 2577-0088 OMB Approval No.: 2502-0355 Public reporting burden for this collection of information is estimated to average .5 hours per response. including the time for reviewing instructions. searching existing data sources. gathering and maintaining the data needed. and completing and reviewing the collection of information. The Information is voluntary. HUD may not collect this information. and you are not required to complete this form. unless it displays a currently valid OMB Control Number. Executive Orders dated July 14, 1983. directs the Minority Business Development Plans shall be developed by each Federal Agency and the these annual plans shall establish minority business development objectives. The information is used by HUD to monitor and evaluate MBE activities against the total program activity and the designated minority business enterprise (MBE) goals. The Department requires the information to provide guidance and oversight for programs for the development of minority business enterprise concerning Minority Business Development. If the information is not collected HUD would not be able to establish meaningful MBE goals nor evaluate MBE performance against these goals. Privacy Act Notice = The United States Department of Housing and Urban Development, Federal Housing Administration. is authorized to solicit the Information requested in this form by virtue of Title 12. United States Codc, Section 1701 et seq . and regulation. It will not be disclosed or rclesed outside the United States Department of Housing and Urban Development without your consetn, except as required or permitted by Law. 1. Gmntee/Project Owner/Developer/Sponsor/Builder/Agency Citv of Fort Worth 3a, Name of Contact Person 3b. Phone Number (Including Ares Codc) Sarah Burkett 817-392-7538 Grant/Project Number or HUD Case Number or other Type of Trade identification of property. Amount of Contract Code subdivision. dwelling unit, etc. or Subcontract (See below) 7a. 7b. 7c, 7d. CPD: 1 - New Construction 2 = Education/Training 3 = Other Previous editions are obsolete. Contractor or Subcontractor Business Racial/Ethnic (See below) Woman Owned Business (Ycs or No) Scc. 3 Business 7c. (Yes or No) 7c: Type of Trade Codes: Housing/Public Housing: 1 = Now Construction 2 = Substantial Rehab 3 = Repair 4 a Service 5 - Project Mangt 6 = Professional 7 = Tenant Services 8 = Education/Training 9 - Arch/Engrg. Appraisal 0 - Other Prime Contractor Identification (ID) Number 7f, 4. Reporting Period © Oct 1 - Sent. 30 (Annual -11Y1 Scc. 3 7g. Subcontractor Identification (ID) Number 7h 7d: Racial/Ethnic Codes: 1 - White Americans 2 = Black Americans 3 - Native Americans 4 - Hispanic Americans 5 = Ashur/Pacific Americans 6 = Hasidic Jews Scc. 3 7i. Check if PH IH CPD Housing 5. Program Code (Not applicable for CPI programs.) See explanation of Codes at bottom of P ge Use a separate sheet for each program code. Contractor/Subcontractor Name and Address Name 2. Location (City. State Zip Code) 1000 Throckmorton. Fort Worth. TX 76102 Street 6 Date Submitted to Field Office City State 5: Program Codes (Complete for Housing and Public and Indian Housing programs only): 1 - All Insured, including Section8 2= Flexible Subsidy 3 = Section 8 Noninsured, Non-HFDA 4 = Insured (Management) 5 - Section 202 6 = HUD -Held (Management) 7 - Public/India Housing 8 - Section 811 form HUD-2516 (8/98) 7j. ZiD 11 New b New Hires are °a See.3 Hires See, 3 Res. New Hires #DIV/0I #DIV/01 #DIV/01 #DIV/0! #DIV/01 #DIV/01 #DIV/01 #DIV/01 #DIV/01 I #DIV/0! I #DIV/01 #DIV/01 #DIV/01 #DIV/01 #DIV/01 # DIV/01 #DIV/0I #DIV/01 #DIV/0! #DIV/01 This report is to be completed by grantees, developers, sponsors, builders, agencies, and/or project owners for reporting contract and subcontract activities of $10,000 or more under the following programs: Community Development Block Grants (entitlement and small cities); Urban Development Action Grants; Housing Development Grants; Multifamily Insured and Noninsured; Public and Indian Housing Authorities; and contracts entered into by recipients of CDBG rehabilitation assistance. Contracts/subcontracts of less than $10,000 need be reported only if such contracts represent a significant portion of your total contracting activity. Include only contracts executed during this reporting period. This form has been modified to capture Section 3 contract data in columns 7g and 7i. Section 3 requires that the employment and other economic opportunities generated by HUD financial assistance for housing and community development programs shall, to the greatest extent feasible, be directed toward low- and very low-income persons, particularly those who are recipients of government assistance for housing. Recipients using this form to report Section 3 contract data must also use Part I of form HUD-60002 to report employment and training opportunities data. Form HUD-2516 is to be Community Development Programs 1. Grantee: Enter the name of the unit of government submitting this report. 3. Contact Person: Enter name and phone of person responsible for maintaining and submitting contract/subcontract data, 7a. Grant Number: Enter the HUD Community Development Block Grant Identification Number (with dashes). For example: B-32-MC-25-0034. For Entitlement Programs and Small City multi -year comprehensive programs, enter the latest approved grant number. 7b. Amount of Contract/Subcontract: Enter the dollar amount rounded to the nearest dollar. If subcontractor ID number is provided in 7f, the dollar figure would be for the subcontract only and not for the prime contract. 7c. Type of Trade: Enter the numeric codes which best indicates the contractor's/subcontractor's service. If subcontractor ID number is provided in 7f., the type of trade code would be for the subcontractor only and not for the prime contractor. The "other" category includes supply, professional services and all other activities except construction and education/training activities. 7d. Business Racial/Ethnic/Gender Code: Enter the numeric code which indicates the racial/ethnic/gender character of the owner(s) and controller(s) of 51% of the business. When 51% or more is not owned and controlled by any single racial/ethnic/gender category, enter the code which seems most appropriate. If the subcontractor ID number is provided, the code would apply to the subcontractor and not to the prime contractor. 7e. Woman Owned Business: Enter Yes or No. 7f. Contractor Identification (ID) Number: Enter the Employer (IRS) Number of the Prime Contractor as the unique identifier for prime recipient of HUD funds. Note that the Employer (IRS) Number must be provided for each contract/subcontract awarded. 7g. Section 3 Contractor: Enter Yes or No. 7h. Subcontractor Identification (ID) Number: Enter the Employer (IRS) Number of the subcontractor as the unique identifier for each subcontract awarded from HUD funds. When the subcontractor ID Number is provided, the respective Prime Contractor ID Number must also be provided. 7i. Section 3 Contractor: Enter Yes or No. 7j. Contractor/Subcontractor Name and Address: Enter this information for each firm receiving contract/subcontract activity only one time on each report for each firm. completed for public and Indian housing and most community development programs. Form HUD- 60002 is to be completed by all other HUD programs including State administered community development programs covered under Section3. A Section 3 Contractor/subcontractor is a business concern that provides economic opportunities to low and very Low-income residents of the metropolitan area (or nonmetropolitan county), including a business concern that is 51 person or more owned by low-income residents; or provides subcontracting or business development opportunities to businesses owned by low or low-income residents. Low and very low-income residents; include participants in Youthbuild programs established under Subtitle D of Title IV of the Cranston -Gonzalez National Affordable Housing Act. The terms "low-income persons" and "very low-income persons" have the same meanings given the terms in section3(b)(2) of the United States Housing Act of 1937. Low-income persons mean families (including single persons) whose incomes do not exceed 80 per centum of the median income for the area, as determined by the Secretary, with adjustments for smaller an larger families, except that the Secretary may establish income ceilings higher or lower than 80 per centum of the median for the area on the basis of the Secretary's findings that such variations are necessary because of prevailing levels of construction Multifamily Housing Programs 1. Grantee/Project Owner: Enter the name of the unit of government, agency or mortgagor entity submitting this report. 3. Contact Person: Same as item 3 under CPD Programs. 4. Reporting Period: Check only one period. 5. Program Code: Enter the appropriate program code. 7a. Grant/Project Number: Enter the HUD Project Number or Housing Development Grant or number assigned. 7b. Amount of Contract/Subcontract: Same as item 7b. under CPD Programs. 7c. Type of Trade: Same as item 7c. under CPD Programs. 7d. Business Racial/Ethnic/Gender Code: Same as item 7d. under CPD Programs. 7e. Woman Owned Business: Enter Yes or No. 7f. Contractor Identification (ID) Number: Same as item 7f. under CPD Programs. 7g. Section 3 Contractor: Enter Yes or No. 7h. Subcontractor Identification (ID) Number: Same as item 7h. under CPD Programs. 7i. Section 3 Contractor: Enter Yes or No. 7j. Contractor/Subcontractor Name and Address: Same as item 7j. under CPD Programs. costs or unusually high or low-income families. Very low-income families (including single persons) whose incomes do not exceed 50 per centum of the median family income for the area, as determined by the Secretary with adjustments for smaller and larger families, except that the secretary may establish income ceilings higher or lower than 50 per centum of the median for the area on the basis of the Secretary's findings that such variations are necessary because of unusually high or low family incomes. Submit two (2) copies of this report to your local HUD Office within ten (10) days after the end of the reporting period you checked in item 4 on the front. Complete item 7h. Only once for each contractor/subcontractor on each semi-annual report. Enter the prime contractor's ID in item 7f. for all contracts and subcontracts. Include only contracts expected during this reporting period. PHAs/IHAs are to report all contracts/subcontracts. Public Housing and Indian Housing Programs PHAs/IRAs are to report all contracts/subcontracts. Include only contracts executed during this reporting period. 1. Project Owner: Enter the name of the unit of government, agency or mortgagor entity submitting this report. Check box as appropriate. 3. Contact Person: Same as item 3 under CPD Programs. 4. Reporting Period: Check only one period. 5. Program Code: Enter the appropriate program code. 7a. Grant/Project Number: Enter the HUD Project Number or Housing Development Grant or number assigned. 7b. Amount of Contract/Subcontract: Same as item 7b. under CPD Programs, 7c. Type of Trade: Same as item 7c. under CPD Programs. 7d. Business Racial/Ethnic/Gender Code: Same as item 7d. under CPD Programs. 7e. Woman Owned Business: Enter Yes or No. 7f. Contractor Identification (ID) Number: Same as item 7f, under CPD Programs. 7g. Section 3 Contractor: Enter Yes or No. 7h. Subcontractor Identification (ID) Number: Same as item 7h, under CPD Programs. 7i. Section 3 Contractor: Enter Yes or No. 7j. Contractor/Subcontractor Name and Address: Same as item 7j. under CPD Programs. M&C Review official site of;t e;-itv o I7`V. COUNCIL=AGEN »A CONTINUED FROM A PREVIOUS WEEK REFERENCE 17NS DATE: 7/28/2015 NO.: G-18521 LOG NAME: HUDACTIONPLANPY2015- 2016 CODE G TYPEw NON- PUBLIC CONSENT HEARING: YES SUBJECT: Conduct Two Public Hearings and Approve the City's 2015-2016 Action Plan for the Use of Federal Grant Funds in the Amount of $9,820,979.00 from the United States Department of Housing and Urban Development from the Community Development Block Grant, HOME Investment Partnerships Program, Emergency Solutions Grant and Housing Opportunities for Persons with AIDS Grant Programs, Authorize Collection and Use of Program Income, Authonze Waiver of Application of Indirect Cost Rates Authorize Execution of Related Contracts and Adopt Appropriation Ordinance (ALL COUNCIL DISTRICTS) RECOMMENDATION: It is recommended that the City Council: 1. Conduct two public hearings to allow citizen input and consideration of the City's 2015-2016 Action Plan for use of federal grant funds from the United States Department of Housing and Urban Development in the amount of $9,820,979.00 from the Community Development Block Grant, HOME Investment Partnerships Program, Emergency Solutions Grant and Housing Opportunities for Persons with AIDS grant programs and for the use of program income from activities using prior years' federal grant funds; 2. Approve the City's 2015-2016 Action Plan for submission to the United States Department of Housing and Urban Development including allocations of grant funds to particular programs and activities as detailed below; 3. Authorize the collection and use of an estimated $50,000.00 of program income, which resulted from activities using prior years' Community Development Block Grant fund, for the reconstruction of City streets; 4. Authorize the collection and use of an estimated $200,000.00 of program income, which resulted from activities using prior years' HOME Investment Partnerships Program funds, for the City's Homebuyer Assistance Program, 5. Authorize the City Manager or his designee to execute contracts for a one-year term with the agencies listed in Tables 1, 2 and 3 below for Program Year 2015-2016 for Community Development Block Grant, Emergency Solutions Grant and Housing Opportunities for Persons with AIDS grant funds, contingent upon receipt of funding; 6.i Authorize the City Manager or his designee to extend the contracts for up to one year if an agency or department requests an extension and such extension is necessary for completion of the program or to amend the contracts if necessary to achieve program goals provided any amendment is within the scope of the program and in compliance with City policies and all applicable laws and regulations governing the use of federal grant funds; FORT WoRTH http://apps.cfwnet.org/council_packet/mc review.asp?ID=21233&councildate=8/4/2015[8/5/2015 8:44:59 AM] M&C Review 7. Authorize a waiver of indirect cost rates as applicable for the Grants Fund in accordance with the City's Administrative Regulations; and 8 Adopt the attached appropriation ordinance increasing the estimated receipts and appropriations to the Grants Fund in the total amount of $9,820,979 00 consisting of $6 332,270.00 in Community Development Block Grant funds, $1,934,447.00 in HOME Investment Partnerships Program funds, $552,108.00 in Emergency Solutions Grant funds and $1,002,154.00 in Housing Opportunities for Persons with AIDS grant funds, plus any program income, all subject to receipt of such funds. DISCUSSION: The City s 2015-2016 Action Plan summarizes the major housing and community development activities and proposed expenditures for the program year beginning October 1, 2015 and ending September 30, 2016 for use of federal grant funds totaling $9,820,979.00 from the United States Department of Housing and Urban Development (HUD) for Community Development Block Grant (CDBG), HOME Investment Partnerships Program (HOME), Emergency Solutions Grant (ESG) and Housing Opportunities for People with AIDS (HOPWA) grant programs. It also summarizes the use of program income resulting from activities using prior years' CDBG and HOME funds. The purpose of these grant funds is to primarily benefit low and moderate income City residents with ESG funds primarily benefiting homeless persons and HOPWA funds primarily benefiting persons with HIV/AIDS. Staff developed recommendations for the allocation of the estimated funding from HUD and presented them to the Community Development Council (CDC) on May 20, 2015 and to the City Council at its Pre -Council meeting on June 16, 2015. Notice of a 30-day public comment period from July 1 2015 to July 31, 2015 was published in the Fort Worth Star -Telegram on June 28 2015. Any comments received will be maintained by the Neighborhood Services Department in accordance with federal regulations. The City will hold two public hearings as part of the HUD - required citizen participation process, the first on July 28, 2015 and the second on August 4, 2015 at which time the City Council is scheduled to approve the Action Plan. In addition, public hearings were held on June 18, 2015 at 11:30 a m. and 6:00 p.m. for citizens to provide comment on the proposed list of neighborhood streets eligible for reconstruction using CDBG funds. A summary of the CDC's funding recommendations is provided below in Tables 1 2 and 3 and a spreadsheet of all specific funding recommendations is attached The 2015-2016 Action Plan must be submitted to HUD by August 14, 2015. CDBG For Program Year 2015-2016, it is recommended that the amount of $6,332,270.00 in CDBG funds and the estimated amount of $50,000.00 of CDBG program income be allocated as follows: Public Services - $949,840.00 This item includes social services for low to moderate income, disabled and disadvantaged populations. Housing Programs and Services - $2,175,600.00 This item includes funding for the City's Priority Repair Program, Cowtown Brush -Up homebuyer and housing services, accessibility modifications to the homes of senior and/or disabled individuals and related project delivery costs for these programs. Infrastructure Services - $1,201,521.53 This item includes funding for the reconstruction of neighborhood streets. http://apps.cfwnet.org/council_packet/mc review.asp9ID=21233&councildate=8/4/2015[8/5/2015 8:44:59 AM] M&C Review CDBG Economic Development - $738,854.47 This item is the City's annual payment on its Section 108 loan from HUD. CDBG Estimated Program Income - $50,000.00 This item includes funding for the reconstruction of City streets in addition to the funds listed above under Infrastructure Services. CDBG program income that is received which is over the estimated amount but not used for reconstruction of City streets will be allocated to priority activities in the City's Consolidated Plan subject to Council approval. CDBG General Administration - $1,266,454.00 This item includes costs for administering the CDBG grant including allocations for Financial Management Services, Internal Audit and Transportation and Public Works Departments. HOME For Program Year 2015-2016, it is recommended that the amount of $1,934,447.00 in HOME funds and the estimated amount of $200,000.00 of HOME program income be allocated as follows: Homebuyer Assistance Program (HAP) - $1,097,400.00 This item includes funding for down payment and/or closing cost assistance to low and moderate income homebuyers. Community Development Housing Organizations (CHDO) Set Aside - $290,168.00 HUD requires that a minimum of 15 percent of HOME funds be allocated to CHDOs for affordable housing projects and CHDO administrative operating costs. These funds will be used by Tarrant County Housing Partnership, Inc. (TCHP), a CHDO, to construct additional single family houses for the 21 lot Hardy Street Single Family Infill Development in the Diamond Hill -Jarvis neighborhood (Council District 2). The houses will be sold to homebuyers making at or below 80 percent of area median income set by HUD. Single -Family Development - $353,435 00 This item includes funding for construction by TCHP of additional single family houses for the Hardy Street Single Family Infill Development HOME General Administration - $193,444.00 This item includes costs for administering the HOME grant. HOME Estimated Program Income - $200,000.00 This item includes funding for the City's HAP for closing cost and/or down payment assistance in addition to the funds listed above. HOME program income that is received which is over the estimated amount but not used for HAP will be allocated to priority activities in the City's Consolidated Plan subject to Council approval. HUD allows the City to take 10 percent of any HOME program income to be used for the costs for administering the HOME grant. HOPWA For Program Year 2015-2016, it is recommended that the amount of $1,002,154.00 in HOPWA funds be allocated as follows: Non -Profit Service Providers $972,090.00 HOPWA Program Administration - $30,064.00 ESG http://apps.cfwnet.org/council packet/mc review.asp7ll=21233&councildate=8/4/2015[8/5/2015 8:44:59 AM] M&C Review For Program Year 2015-2016, it is recommended that the amount of $552,108.00 in ESG funds be allocated as follows: Non -Profit Service Providers - $510,700.00 ESG Program Administration - $41,408.00 CONTRACT RECOMMENDATIONS The CDC and Staff recommend that contracts be executed with the listed agencies for the amounts shown in the following tables: Community Development Block Grant Contracts: Table 1 - CDBG Agencies Organization Cenikor Foundation Senior Citizen Services of Greater Tarrant County Inc. YMCA of Metropolitan Fort Worth YWCA of Fort Worth and Tarrant County Clayton Child Care Inc. d/b/a Clayton YESI Girls Inc. of Tarrant County Camp Fire First Texas Lena Pope Home, Inc. The Ladder Alliance Tarrant County Housing Partnership, Inc. Presbyterian Night Shelter The Salvation Army, a Georgia Corporation Meals on Wheels, Inc. of Tarrant County CDBG Public Service Subtotal Rehabilitation Education and Advocacy for Persons with Handicaps, dba REACH, Inc.** Total CDBG Contracts Program Substance Abuse Senior Services Child Care Services Child Care Services Child Care Services Youth Services Youth Services Youth Services Employment/Job Training Housing Counseling and Education Case Management/Main Shelter Amount $ 75,000.00 $ 75,000.00 $ 75,000.00 $ 49,840.00 $ 75,000.00 $ 75,000.00 $ 75,000.00 $ 75,000.00 $ 75,000.00 $ 75,000.00 $ 75,000.00 Homeless Services $ 75,000.00 $ 75,000.00 $ 949,840.00 Project Ramp $ 100,000.00 Home -delivered Meals Program **REACH will be funded from the CDBG Housing Programs $1,049,840.00 and Services budget. http://apps.cfwnet.org/council packet/me review.asp9ID=21233&councildate=8/4/2015[8/5/2015 8:44:59 AM] M&C Review Housina Opportunities For Persons With AIDS Contracts: Organization Tarrant County Samaritan Housing, Inc. AIDS Outreach Center, Inc. TOTAL HOPWA Contracts Oraanizatiort S afeHaven of Tarrant County P resbyterian Night Shelter Day Resource Center for the Homeless The Salvation Army, a Georgia Corporation YWCA Fort Worth and Tarrant County TOTAL ESG Contracts Table 2 - HOPWA Agencies Program Administration (seven percent) Supportive Services Amount and Facility Based Housing Subsidy Assistance $420,063.00 Administration (seven percent), Supportive Services, Tenant Based Rental Assistance (TBRA), and Short $552,027.00 Term Rent Mortgage and Utility Assistance (STRMU) Emeraencv Solutions Grant Contracts: Table 3 - ESG Agencies Proaram S helter Services S helter Services S helter Services Homelessness P revention Rapid Re -Housing These programs are available in ALL COUNCIL DISTRICTS. $972,090.00 Amount $104,265.00 $ 85,908.00 $141,092.00 $100,000.00 $ 79,435.00 $510,700.00 FISCAL INFORMATION/CERTIFICATION: The Financial Management Services Director certifies that upon approval of the above recommendations, adoption of the attached appropriation ordinance and receipt of grant funds, funds will be available in the current operating budget as appropriated, of the Grants Fund. TO Fund/AccountlCentens FROM Fund/Account/Centers 21001 4310013 019CDBG $6 332.270,00 http://apps.cfwnet.org/council packetlmc review.asp9ID 21233&councildate=8/4/2015[8/5/20158:44:59AM) M&C Review 21001 21001 21001 21001 21001 21001 21001 21001 21001 21001 21001 5XXXXXX 019CDBG 4310013 019HOME 5XXXXXX 019HOME 4310013 019ESG 5XXXXXX 019ESG 4921001 019CDBG 5XXXXXX 019CDBG 4310013 019HOPW9 5XXXXXX 019HOPWA 4921001 019HOME 5XXXXXX 019HOME $6.332.270.00 $1.934.447.00 $1.934.447.00 $552.108.00 $552.108.00 $50.000.00 $50.000.00 $1 002.154.00 $1.002.154.00 $200.000.00 $200.000.00 Submitted for City Manaaer's Office by: Oriainatina Department Head: Additional Information Contact Fernando Costa (6122) Allison Gray (8030) Avis Chaisson (6342) Leticia Rodriguez (7319) ATTACHMENTS 17NS HUDACTIONPLANPY2015-2016 GR76 AO FY2015.docx, Action Plan 15 16 FINAL MandC Slides LHR.odf Proposed 2015 CDBG Infrastructure Project MandC.odf http://apps.cfwnet.org/council packet/me review.asp?ID=21233&councildate=8/4/2015[8/5/2015 8:44:59 AM]